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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1033155



Case Details

VAERS ID: 1033155 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2021-02-11
Onset:2021-02-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Craniocerebral injury, Death, Endotracheal intubation, Fall, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amiodarone, Rosuvastatin, Prevacid, Zetia, ASA, MVI, Nitroglycerin, Metformin, Potassium, Bumex, Apixaban, Omega 3, Metoprolol, Midodrine,
Current Illness: Generalized ischemic myocardial dysfunction, lower leg edema with cellulitis
Preexisting Conditions: Ischemic Cardiomyopathy, Diabetes, Combined Systolic/Diastolic Heart Failure, Edema, Ventricular Tachycardia, Pacemaker, Stroke, Myocardial Infarction, Hyperlipidemia, Hypertension, Obesity, Coronary arteriosclerosis, Paroxysmal atrial fibrillation, Left ventricular thrombus, Cardiorenal Sydrome, Bilateral lower leg cellulitis
Allergies: No known allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Vaccine given in clinic per protocol - patient monitored for 15 minutes, no adverse reactions noted at the time. Patient stated he felt fine following 15 minute monitoring time. Patient left facility- it was later reported that pt had a fall at home. Upon review of pt''s medical record - Pt''s wife had to initiate CPR and call EMS for transportation and life saving measures enroute to the Emergency Room. Pt was intubated as pt was in asystole upon arrival to the ER, ACLS was continued, pt was noted to have a traumatic brain injury from his fall at home, and pt was pronounced dead at 1620.


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