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This is VAERS ID 1125079

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1125079
VAERS Form:2
Age:
Sex:Male
Location:Michigan
Vaccinated:2021-02-02
Onset:2021-03-03
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-03
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: COVID-19 (Patient was diagnosed with Covid-19 prior to first dose.); Dehydration (The patient was reported to be dehydrated prior to testing positive for Covid-19)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Patient passed away; Found him non-responsive; A spontaneous report was received from a consumer concerning a male patient of an unknown age who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced unresponsiveness to stimulus. The event was followed by his death. The patient''s medical history included Covid-19 and experienced dehydration prior to testing positive for Covid-19. Concomitant product use was not provided by the reporter. The patient was diagnosed with COVID-19 at the skilled facility after becoming dehydrated. He was transported to Hospital on 23 Dec 2020 then discharged to skilled facility on 03 Jan 2021 for physical therapy. On 02 Feb 2021, the patient received their first of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 02 Mar 2021, the patient received their second of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly for prophylaxis of COVID-19 infection. The anatomical location were not reported. On 03 Mar 2021, the patient was found non-responsive and the staff at skilled rehabilitation tried to resuscitate. Death was the outcome. Treatment information was not provided. Action taken with mRNA-1273 in response to the event(s) was not applicable. The outcome of the event non responsive to stimuli was fatal. The patient died-on 03 Mar 2021 and the cause of death was not provided. It is not known whether autopsy done on this individual. No results were provided.; Reporter''s Comments: This is a case of death in an unknown aged male subject with unknown medical history of recently recovered covid-19 infection before first dose, who died one day after receiving second dose of vaccine. Very limited information has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/7/2021

VAERS ID: 1125079 Before After
VAERS Form:2
Age:
Sex:Male
Location:Michigan
Vaccinated:2021-02-02
Onset:2021-03-03
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-03
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: COVID-19 (Patient was diagnosed with Covid-19 prior to first dose.); Dehydration (The patient was reported to be dehydrated prior to testing positive for Covid-19)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Patient passed away; Found him non-responsive; A spontaneous report was received from a consumer concerning a male patient of an unknown age who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced unresponsiveness to stimulus. The event was followed by his death. The patient''s medical history included Covid-19 and experienced dehydration prior to testing positive for Covid-19. Concomitant product use was not provided by the reporter. The patient was diagnosed with COVID-19 at the skilled facility after becoming dehydrated. He was transported to Hospital on 23 Dec 2020 then discharged to skilled facility on 03 Jan 2021 for physical therapy. On 02 Feb 2021, the patient received their first of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 02 Mar 2021, the patient received their second of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly for prophylaxis of COVID-19 infection. The anatomical location were not reported. On 03 Mar 2021, the patient was found non-responsive and the staff at skilled rehabilitation tried to resuscitate. Death was the outcome. Treatment information was not provided. Action taken with mRNA-1273 in response to the event(s) was not applicable. The outcome of the event non responsive to stimuli was fatal. The patient died-on 03 Mar 2021 and the cause of death was not provided. It is not known whether autopsy done on this individual. No results were provided.; Reporter''s Comments: This is a case of death in an unknown aged male subject with unknown medical history of recently recovered covid-19 infection before first dose, who died one day after receiving second dose of vaccine. Very limited information has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/14/2021

VAERS ID: 1125079 Before After
VAERS Form:2
Age:
Sex:Male
Location:Michigan
Vaccinated:2021-02-02
Onset:2021-03-03
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-03
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: COVID-19 (Patient was diagnosed with Covid-19 prior to first dose.); Dehydration (The patient was reported to be dehydrated prior to testing positive for Covid-19)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Patient passed away; Found him non-responsive; A spontaneous report was received from a consumer concerning a male patient of an unknown age who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced unresponsiveness to stimulus. The event was followed by his death. The patient''s medical history included Covid-19 and experienced dehydration prior to testing positive for Covid-19. Concomitant product use was not provided by the reporter. The patient was diagnosed with COVID-19 at the skilled facility after becoming dehydrated. He was transported to Hospital on 23 Dec 2020 then discharged to skilled facility on 03 Jan 2021 for physical therapy. On 02 Feb 2021, the patient received their first of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 02 Mar 2021, the patient received their second of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly for prophylaxis of COVID-19 infection. The anatomical location were not reported. On 03 Mar 2021, the patient was found non-responsive and the staff at skilled rehabilitation tried to resuscitate. Death was the outcome. Treatment information was not provided. Action taken with mRNA-1273 in response to the event(s) was not applicable. The outcome of the event non responsive to stimuli was fatal. The patient died-on 03 Mar 2021 and the cause of death was not provided. It is not known whether autopsy done on this individual. No results were provided.; Reporter''s Comments: This is a case of death in an unknown aged male subject with unknown medical history of recently recovered covid-19 infection before first dose, who died one day after receiving second dose of vaccine. Very limited information has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death

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