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

This is VAERS ID 1051263



Case Details

VAERS ID: 1051263 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-27
Onset:2021-02-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Brain hypoxia, Coma, Death, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: PHENOBARBITAL; LAMICTAL; KEPPRA
Current Illness: Seizures
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; Found unconscious; Coma; Lack of oxygen to the brain; A spontaneous report was received from a consumer, concerning his mother, a 71-year-old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and passed away, prior to death, patient experienced lack of oxygen to the brain and was found unconscious and went to coma. The patient''s medical history reported included seizures. Concomitant medications included phenobarbital, lamotrigine and levetiracetam. On 27 Jan 2021, approximately six days prior to the onset of events, the patient received their first of two planned doses of mRNA-1273 (lot number: 030L20A) intramuscularly for prophylaxis of COVID-19 infection. On 01 Feb 2021 at 4 am, the patient was found to be unconscious on the couch, hence she was rushed to the hospital with lack of oxygen to the brain. Later, she went into a coma, hence she was in hospital for 30 hours and then was transferred to a different hospital for a second opinion on 06-Feb-2021, where she was passed away at 02:20 PM. Treatment information was not provided Action taken with mRNA-1273 in response to the events were not applicable. The outcome of events, lack of oxygen to the brain, found unconscious and coma were considered unknown. The outcome of event passed away was fatal as she died on 06 Feb 2021 at 2:20 pm. The cause of death was not provided. Plans for an autopsy were unknown.; Reporter''s Comments: This is a case of 71-year-old female subject with a history of seizures who died 6 days after receiving first dose of vaccine. Very limited information has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Passed away


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