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

This is VAERS ID 1206443



Case Details

VAERS ID: 1206443 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-03-10
Onset:2021-03-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3000493 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   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: ESOMEPRAZOLE; NICOBION; TRIMBOW; LEXOMIL 6 mg, double-scored tablet; OROCAL; VENLAFAXINE; VITAMINE B1 B6 BAYER; VENTOLINE
Current Illness: Cachexia
Preexisting Conditions: Medical History/Concurrent Conditions: COPD (Gold IV); Depression; Dyspnoea on effort; Reflux esophagitis (Grade 3); Smoker; Ulcer peptic
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRMODERNATX, INC.MOD20210

Write-up: Sudden death unexplained; This regulatory authority case was reported by a physician and describes the occurrence of SUDDEN DEATH (Sudden death unexplained) in a 77-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3000493) for COVID-19 vaccination. The patient''s past medical history included Ulcer peptic, Depression, COPD (Gold IV), Smoker, Reflux esophagitis (Grade 3) and Dyspnoea on effort. Concurrent medical conditions included Cachexia. Concomitant products included ESOMEPRAZOLE, NICOTINAMIDE (NICOBION), BECLOMETASONE DIPROPIONATE, FORMOTEROL FUMARATE, GLYCOPYRRONIUM BROMIDE (TRIMBOW), BROMAZEPAM (LEXOMIL 6 mg, double-scored tablet), CONCENTRAT DE CHOLECALCIFEROL, FORME PULVERULENTE, CALCIUM (CARBONATE DE), CARBONATE DE CALCIUM (OROCAL), VENLAFAXINE, PYRIDOXINE HYDROCHLORIDE, THIAMINE HYDROCHLORIDE (VITAMINE B1 B6 BAYER) and SALBUTAMOL (SULFATE DE), SULFATE DE SALBUTAMOL (VENTOLINE) for an unknown indication. On 10-Mar-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. The patient died on 11-Mar-2021. The reported cause of death was Sudden death unexplained. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. No treatment information was provided . This case was received from a regulatory authority (FR-AFSSAPS-NY20210563). Reporter did not allow further contact; Sender''s Comments: Very limited information regarding this event has been provided at this time. Patient''s advanced age along with underlying conditions may have been contributory for the occurrence of the death. No further follow-up information is expected.; Reported Cause(s) of Death: Sudden death unexplained


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