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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1056295



Case Details

VAERS ID: 1056295 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2020-12-31
Onset:2021-01-05
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ 0724 / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Blood pressure measurement, Body temperature, COVID-19, COVID-19 pneumonia, Confusional state, Heart rate, Hypertension, Malaise, Oxygen saturation, Respiratory rate, SARS-CoV-2 test
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ADIZEM-XL; ACETYLSALICYLIC ACID; ATORVASTATIN; RAMIPRIL
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 pneumonia; Ex-smoker (Ex-smoker (stopped 2015, unable to establish pack years from notes)); Hypertension; Peripheral arterial disease; Comments: HTN, Ex-smoker (stopped 2015, unable to establish pack years from notes), IGR, PAD. Unsure if patient is enrolled in clinical trial
Allergies:
Diagnostic Lab Data: Test Name: Blood pressure; Result Unstructured Data: Test Result:160/80; Test Name: Body temperature; Result Unstructured Data: Test Result:39.7; Test Name: Heart rate; Result Unstructured Data: Test Result:90; Test Name: Oxygen saturation; Test Result: 90 %; Test Name: Oxygen saturation; Result Unstructured Data: Test Result:less than 90 %; Test Name: Respiratory rate; Result Unstructured Data: Test Result:28; Test Date: 20210111; Test Name: COVID-19 virus test; Result Unstructured Data: Test Result:Yes - Positive COVID-19 test
CDC Split Type: GBPFIZER INC2021185944

Write-up: hypertension; unwell; confused state; SARS-CoV-2 infection; COVID-19 pneumonia; This is a spontaneous report from a contactable other healthcare professional (other HCP) received from the MHRA. Regulatory authority report number is GB-MHRA-WEBCOVID-202102180927046120, Safety Report Unique Identifier is GB-MHRA-ADR 24784988. A 79-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; lot number: EJ 0724) via an unspecified route of administration on 31Dec2020 at a single dose for covid-19 immunisation. Medical history included covid-19 pneumonia, hypertension, ex-smoker (stopped 2015, unable to establish pack years from notes), IGR, and peripheral arterial disease (PAD). Unsure if patient was enrolled in clinical trial. Concomitant medication included diltiazem hydrochloride (ADIZEM-XL) from 12May2017, acetylsalicylic acid from 11Mar2017 for prophylaxis, atorvastatin from 17Sep2015 for prophylaxis, and ramipril from 12Mar2016 for hypertension. The patient experienced covid-19 pneumonia (death) on 05Jan2021, hypertension (death) on an unspecified date, unwell (non-serious) on an unspecified date with outcome of unknown, confused state (non-serious) on an unspecified date with outcome of unknown, sars-cov-2 infection (non-serious) on 11Jan2021 with outcome of not recovered. Details reported as found on the floor at his home address on 07Jan2021, had been on floor for 2 days. In confused state and had not used alarm system to summons assistance. Ambulance crew used OOH for assessment ad patient. Refused admission to hospital. Obs then, RR28, Hr 90, SpO2 90%oa, BP 160/80, T 39.7c BM6.5. It was attempted to follow up the next working day. Unable to make contact. Ambulance called again on 10Jan2021. SpO2 less than 90%, now too unwell to refuse admission. Admitted to local hospital on 10Jan2021. Patient tested positive Covid-19 on 11Jan2021 in hospital. Onto CPAP. Never recovers. The patient died on 29Jan2021. Cause of death given as Covid pneumonia and hypterension. It was unknown if an autopsy was performed. No follow-up activities are possible. No further information is expected.; Reported Cause(s) of Death: Covid Pneumonia; Hypertension


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