Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0894

2. Registrant Information.

Registrant Reference Number: 877577

Registrant Name (Full Legal Name no abbreviations): McLaughlin Gormley King Company

Address: 8810 Tenth Ave North

City: Minneapolis

Prov / State: MN

Country: USA

Postal Code: 55427-4319

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

31-OCT-11

5. Location of incident.

Country: UNITED STATES

Prov / State: ARIZONA

6. Date incident was first observed.

Unknown

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 1021-1855-79529

Product Name: BLACK FLAG One Shot Ant & Roach Killer

  • Active Ingredient(s)
    • CYPERMETHRIN
      • Guarantee/concentration .03 %
    • PRALLETHRIN
      • Guarantee/concentration .011 %
    • PYRETHRINS
      • Guarantee/concentration .011 %

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Chihuahua

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

5.00

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Foaming at mouth
    • Symptom - Vomiting
  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify No definable point of exposure with the pesticide occurred.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

10/31/2011 Caller applied the product to an area outside around the front steps 3 days ago. Several hours later, the dog was allowed free access to the area where product had been applied. The dog was never actually seen directly on the area or sniffing around the area. On the following day, the dog developed clear vomiting, foaming at the mouth, and died the same day. The dog has since been buried. The dog was never evaluated by a veterinarian.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. Any relationship between the use of this product and the development of the complications reported in this case is inconceivable and lacks biological plausibility. Secondly, the product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with a surface treated with this pesticide occurred, such serious illness as reported in this dog is unexpected. Even if true pyrethroid toxicity were to occur in this case it would manifest with acute neurological complications, primarily in the form of tremors and ataxia which were not reported in this incident. Furthermore, this animal was never properly evaluated and treated by a veterinarian, nor had it received proper preventive care in the form of vaccines and anti-parasite treatment prior to the occurrence of this incident.