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This is VAERS ID 1039006

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1039006
VAERS Form:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other      Purchased by: ??
Symptoms: Multiple organ dysfunction syndrome, SARS-CoV-2 test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Diabetes; Ischaemic heart disease; Comments: Heart disease, diabetes Patient has not had symptoms associated with COVID-19 Patient is not enrolled in clinical trial
Diagnostic Lab Data: Test Date: 20210204; Test Name: COVID-19 virus test; Test Result: Negative
CDC 'Split Type': GBPFIZER INC2021155260

Write-up: Multiple organ failure; This is a spontaneous report from a contactable other healthcare professional. This is a report received from the RA. Regulatory authority report number GB-MHRA-APPCOVID-202102131221504710, Safety Report Unique Identifier GB-MHRA-ADR 24756997. A 76-years-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 01Feb2021 at single dose for COVID-19 immunization. Medical history included myocardial ischaemia, diabetes mellitus. The patient''s concomitant medications were not reported. The patient experienced multiple organ failure on 01Feb2021 with outcome of fatal. The patient underwent lab tests included covid-19 virus test: negative on 04Feb2021. The patient died on 06Feb2021. It was not reported if an autopsy was performed. Patient had not had symptoms associated with COVID-19. Patient was not enrolled in clinical trial. Patient had not tested positive for COVID-19 since having the vaccine. No follow-up attempts possible; information regarding batch/lot cannot be obtained.; Reported Cause(s) of Death: Multiple organ failure

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