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

This is VAERS ID 1073225



Case Details

VAERS ID: 1073225 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-02
Onset:2021-02-22
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Ascites, Asthenia, Bacteraemia, Catheter site haemorrhage, Complication associated with device, Condition aggravated, Death, Fall, Haemorrhage, Hip fracture, Hip surgery, Hypotension, Sepsis, Tachycardia
SMQs:, Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol with codeine, albuterol, aspirin, cetirizine, dialyvite, dilaudid, fluticasone, furosemide, multivitamin, glucosamine, lactulose, lantus, nystatin, omeprazole, spironolactone, tramadol, vitamin e, xifaxan
Current Illness: Chronic Illness with debilitation
Preexisting Conditions: chronic hyponatremia, chronic low back pain, ascites, cirrhosis of liver, non-alcoholic fatty liver, dyslipidemia, diabetes, esophageal varisces. obstructive sleep apnea
Allergies: NSAIDS
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 30 days: Admit 2/8/21-2/13/21 s/p fall with left hip fracture (repaired), severe debility with recurrent falls discharged to SNF. Not doing well postop at the SNF, brought to ED due to failed foley insertion with bright red blood upon arrival to ER febrile, hypotensive, tachycardic, severe sepsis. Gran negative bacteremia likely from chronic ascites, family decided on comfort care and he expired within hours of admission.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1073225

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