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This is VAERS ID 1153885

History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 1153885
VAERS Form:2
Age:
Sex:Female
Location:New York
Vaccinated:0000-00-00
Onset:2021-03-11
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: Unknown
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USJNJFOC20210329515

Write-up: ASYSTOLE; PASSED AWAY; This spontaneous report received from a physician concerned their mother-in-law, an female of unspecified age. The patient''s weight, height, and medical history were not reported. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: Unknown) dose was not reported, administered on 11-MAR-2021 for prophylactic vaccination. The batch number was not reported and has been requested. No concomitant medications were reported. On an unspecified date, the patient was in a nursing home, but was hospitalized for pyelonephritis. The patient was not allowed back into the nursing home without a negative COVID test and the vaccine. After discharge from the hospital, the patient''s COVID test came back negative, and upon arrival to the nursing home, the patient received the Janssen COVID-19 vaccine. Within 30 minutes, the patient was unresponsive and transported back to the hospital. On arrival to the hospital, the patient was asystole. She was treated at the hospital until 13-MAR-2021, when she passed away. Asystole was reported as fatal. Additionally, cause of death was reported as "cause unknown", therefore, an additional serious adverse event of "passed away" was captured. An autopsy was not performed. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient died on 13-MAR-2021. This report was serious (Death and Hospitalization).; Sender''s Comments: V0: An female of unknown age became unresponsive 30 minutes after, experienced asystole on the same day as, and died of unknown causes 2 days after receiving Janssen COVID-19 Vaccine Ad26.COV2.S (suspension for injection; route of administration and batch number unknown) for prophylactic vaccination while in a nursing home. Medical history and concomitant medications were not reported. The patient was the mother-in-law of the reporter, an internal medicine physician. The patient had no complaints for 30 minutes after receiving the vaccine, then became unresponsive; she was transported to a hospital where she was noted to be asystolic upon arrival. Treatment and hospital course were not provided. The patient died 2 days after receiving the vaccine, and cause of death was unknown; outcome of asystole was reported as fatal. An autopsy was not performed. This case has insufficient information to make a meaningful medical assessment.; Reported Cause(s) of Death: ASYSTOLE; UNKNOWN CAUSE OF DEATH


Changed on 5/7/2021

VAERS ID: 1153885 Before After
VAERS Form:2
Age:
Sex:Female
Location:New York
Vaccinated:0000-00-00
Onset:2021-03-11
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: Unknown
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USJNJFOC20210329515

Write-up: ASYSTOLE; PASSED AWAY; This spontaneous report received from a physician concerned their mother-in-law, an female of unspecified age. The patient''s weight, height, and medical history were not reported. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: Unknown) dose was not reported, administered on 11-MAR-2021 for prophylactic vaccination. The batch number was not reported and has been requested. No concomitant medications were reported. On an unspecified date, the patient was in a nursing home, but was hospitalized for pyelonephritis. The patient was not allowed back into the nursing home without a negative COVID test and the vaccine. After discharge from the hospital, the patient''s COVID test came back negative, and upon arrival to the nursing home, the patient received the Janssen COVID-19 vaccine. Within 30 minutes, the patient was unresponsive and transported back to the hospital. On arrival to the hospital, the patient was asystole. She was treated at the hospital until 13-MAR-2021, when she passed away. Asystole was reported as fatal. Additionally, cause of death was reported as "cause unknown", therefore, an additional serious adverse event of "passed away" was captured. An autopsy was not performed. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient died on 13-MAR-2021. This report was serious (Death and Hospitalization).; Sender''s Comments: V0: An female of unknown age became unresponsive 30 minutes after, experienced asystole on the same day as, and died of unknown causes 2 days after receiving Janssen COVID-19 Vaccine Ad26.COV2.S (suspension for injection; route of administration and batch number unknown) for prophylactic vaccination while in a nursing home. Medical history and concomitant medications were not reported. The patient was the mother-in-law of the reporter, an internal medicine physician. The patient had no complaints for 30 minutes after receiving the vaccine, then became unresponsive; she was transported to a hospital where she was noted to be asystolic upon arrival. Treatment and hospital course were not provided. The patient died 2 days after receiving the vaccine, and cause of death was unknown; outcome of asystole was reported as fatal. An autopsy was not performed. This case has insufficient information to make a meaningful medical assessment.; Reported Cause(s) of Death: ASYSTOLE; UNKNOWN CAUSE OF DEATH


Changed on 5/14/2021

VAERS ID: 1153885 Before After
VAERS Form:2
Age:
Sex:Female
Location:New York
Vaccinated:0000-00-00
Onset:2021-03-11
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: Unknown
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USJNJFOC20210329515

Write-up: ASYSTOLE; PASSED AWAY; This spontaneous report received from a physician concerned their mother-in-law, an female of unspecified age. The patient''s weight, height, and medical history were not reported. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: Unknown) dose was not reported, administered on 11-MAR-2021 for prophylactic vaccination. The batch number was not reported and has been requested. No concomitant medications were reported. On an unspecified date, the patient was in a nursing home, but was hospitalized for pyelonephritis. The patient was not allowed back into the nursing home without a negative COVID test and the vaccine. After discharge from the hospital, the patient''s COVID test came back negative, and upon arrival to the nursing home, the patient received the Janssen COVID-19 vaccine. Within 30 minutes, the patient was unresponsive and transported back to the hospital. On arrival to the hospital, the patient was asystole. She was treated at the hospital until 13-MAR-2021, when she passed away. Asystole was reported as fatal. Additionally, cause of death was reported as "cause unknown", therefore, an additional serious adverse event of "passed away" was captured. An autopsy was not performed. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient died on 13-MAR-2021. This report was serious (Death and Hospitalization).; Sender''s Comments: V0: An female of unknown age became unresponsive 30 minutes after, experienced asystole on the same day as, and died of unknown causes 2 days after receiving Janssen COVID-19 Vaccine Ad26.COV2.S (suspension for injection; route of administration and batch number unknown) for prophylactic vaccination while in a nursing home. Medical history and concomitant medications were not reported. The patient was the mother-in-law of the reporter, an internal medicine physician. The patient had no complaints for 30 minutes after receiving the vaccine, then became unresponsive; she was transported to a hospital where she was noted to be asystolic upon arrival. Treatment and hospital course were not provided. The patient died 2 days after receiving the vaccine, and cause of death was unknown; outcome of asystole was reported as fatal. An autopsy was not performed. This case has insufficient information to make a meaningful medical assessment.; Reported Cause(s) of Death: ASYSTOLE; UNKNOWN CAUSE OF DEATH

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