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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1157491



Case Details

VAERS ID: 1157491 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Alabama  
Vaccinated:0000-00-00
Onset:2021-03-10
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802070 / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Blood pressure measurement, Circulatory collapse, Headache, Oxygen therapy
SMQs:, Anaphylactic reaction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (broad), Hypersensitivity (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   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:
Current Illness:
Preexisting Conditions: Comments: Unknown
Allergies:
Diagnostic Lab Data: Test Date: 202103101400; Test Name: Oxygen supplementation; Result Unstructured Data: 90''s; Test Date: 202103101400; Test Name: BP; Result Unstructured Data: 145/75
CDC Split Type: USJNJFOC20210341940

Write-up: COLLAPSED; HEADACHE; This spontaneous report received from a consumer concerned a 70 year old male. 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: 1802070 expiry: UNKNOWN) dose was not reported, administered on 10-MAR-2021 11:00 for prophylactic vaccination. No concomitant medications were reported. On 10-MAR-2021, the patient experienced headache, was clammy to the touch. On same day at 14:00, checked blood pressure (BP) and it was 145/75 and his oxygen level read in the 90''s. At 18:00, he collapsed while getting up out of his chair and emergency medical services (EMS) was called performed cardiopulmonary resuscitation (CPR) but never got him back. On 10-MAR-2021, the patient died from cause unknown. An autopsy was not performed. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient died of collapsed on 10-MAR-2021, and the outcome of headache was not reported. This report was serious (Death, and Other Medically Important Condition). The suspected product quality complaint has been confirmed to be no product quality complaint identified within the reported. Complaint is approved for void, based on the PQC evaluation/investigation performed. This report was associated with product quality complaint :90000173895.; Sender''s Comments: V0: 20210341940-COVID-19 VACCINE AD26.COV2.S- COLLAPSED. This event is considered Unassessable. The event has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event.; Reported Cause(s) of Death: Cause unknown


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