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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1035753



Case Details

VAERS ID: 1035753 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-01
Onset:2021-01-22
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood lactic acid, Computerised tomogram thorax, Sepsis, White blood cell count
SMQs:, Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data: Test Date: 20210124; Test Name: Lactate; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Date: 20210124; Test Name: CT thorax; Result Unstructured Data: Revealed abundant thickening in both lungs, no pulmonary embolism, small amount of pericardial fluid.; Test Date: 20210124; Test Name: Leucocyte count; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive
CDC Split Type: NOMODERNATX, INC.MOD20210

Write-up: Death due to sepsis; A regulatory authority report was received from a physician, concerning an 80-year-old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273), experienced death due to sepsis (death, sepsis). The patient''s historical condition was not reported. No concomitant medications were reported. On an unknown date in Jan 2021, prior to the onset of events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On 22 Jan 2021, the patient developed sepsis. On 24 Jan 2021, the patient had laboratory tests reported for computerised tomography (CT) thorax which revealed abundant thickening in both lungs, no pulmonary embolism, small amount of pericardial fluid, leucocyte count was 46 (unknown units), and lactate was 3-7. On the same day, the patient died due to sepsis. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 24 Jan 2021. The cause of death was reported as sepsis. Plans for an autopsy were not provided.; Reporter''s Comments: Very limited information regarding these events has been provided at this time. No further information is expected.; Reported Cause(s) of Death: Sepsis


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