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

This is VAERS ID 1085213



Case Details

VAERS ID: 1085213 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-22
Onset:2021-01-26
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 300042460 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: AMANTADINE; SCOPODERM [HYOSCINE HYDROBROMIDE]; AMLODIPINE; METOPROLOL
Current Illness: COPD; Multiple sclerosis; Syndrome respiratory distress adult (restrictive respiratory syndrome (CV 14% of the predetermined value) with the installation of a non-ventilated invasive (VNI)); Tetraplegia; Urinary infection (recurrent); Von Willebrand''s disease (Type 2 A)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: CHMODERNATX, INC.MOD20210

Write-up: Cardiac arrest; A regulatory report was received from a physician concerning a 53-year-old male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced cardiac arrest and died. The patient''s medical history included restrictive respiratory syndrome, multiple sclerosis, tetraplegia, COPD, urinary infection, and von Willebrand''s disease. The concomitant medications included amantadine, amlodipine, metoprolol, scopolamine/hyoscine. On 22-Jan-2021, the patient received their first of two planned doses of mRNA-1273 (Lot number: 300042460) intramuscularly for prophylaxis of COVID-19 infection. On 26-Jan-2021, 4 days after receiving the vaccine, the patient experienced cardiac arrest and was transported to the hospital in an ambulance. The patient died before arriving. Treatment information was not reported. Action taken with mRNA-1273 was not applicable. On 26-Jan-2021, the patient died due to cardiac arrest. Autopsy details were unknown.; Reporter''s Comments: Very limited information regarding these events has been provided at this time. Patient''s underlying conditions may have been contributory for the occurrence of this fatal event. No further follow-up information is expected.; Reported Cause(s) of Death: Cardiac arrest


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