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

This is VAERS ID 1038234



Case Details

VAERS ID: 1038234 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-01-14
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Condition aggravated, Death, Dementia, Mental impairment, Pyrexia, Urinary tract infection, Wrong product administered
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cephalexin Spiriva, Nitro, Probiotic, Albuterol, Vitamin D3, Multivitamin Aspirin, Glucosamine, Metamucil, Tylenol, Cranberry, Claritin, Quetiapine
Current Illness: Dementia with mental status change Urinary tract infection
Preexisting Conditions: Dementia Hypertension, Chronic UTI Hyperlipidemia, h/o Alcohol Abuse in Remission
Allergies: Sulfa, Aricept
Diagnostic Lab Data:
CDC Split Type:

Write-up: First dose Pfizer given at assisted living on 1/14/21 she was subsequently admitted to hospital and got her second dose but Moderna was given instead of Pfizer on 2/8/21. She had been improving but in the days following the Moderna vaccine she developed fever and then her mental status declined. She was discharged back to assisted living. Suspected UTI, and moderate dementia, placed on hospice (2/12/21). Died on 2/13/21.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1038234

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