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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1468781

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Case Details

VAERS ID: 1468781 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Unknown  
Location: Foreign  
Vaccinated:2021-06-22
Onset:2021-06-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-07-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Body temperature, Cardiac arrest, Depressed level of consciousness, Oxygen saturation, Pyrexia, Stupor
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-26
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: XARELTO; DEMENTIS
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Cardiac pacemaker insertion; Encephalopathy (degenerative encephalopathy); Hip fracture
Allergies:
Diagnostic Lab Data: Test Date: 20210624; Test Name: Body temperature; Result Unstructured Data: 38 degree Celsius; Test Date: 20210625; Test Name: Oxygen saturation; Result Unstructured Data: 83
CDC Split Type: GRMODERNATX, INC.MOD20212

Write-up: Cardiac arrest; Stupor; Fever; Consciousness decreased; This regulatory authority case was reported by an other health care professional and describes the occurrence of CARDIAC ARREST (Cardiac arrest), DEPRESSED LEVEL OF CONSCIOUSNESS (Consciousness decreased), STUPOR (Stupor) and PYREXIA (Fever) in a 74-year-old patient of an unknown gender who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. The patient''s past medical history included Encephalopathy (degenerative encephalopathy) in November 2020, Hip fracture in December 2020 and Cardiac pacemaker insertion. Concomitant products included RIVAROXABAN (XARELTO) from 12-Aug-2020 to an unknown date and DONEPEZIL HYDROCHLORIDE (DEMENTIS) for an unknown indication. On 22-Jun-2021, the patient received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On an unknown date, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 24-Jun-2021, the patient experienced DEPRESSED LEVEL OF CONSCIOUSNESS (Consciousness decreased) (seriousness criteria death and medically significant) and PYREXIA (Fever) (seriousness criteria death and medically significant). On 25-Jun-2021, the patient experienced STUPOR (Stupor) (seriousness criteria death and medically significant). On 26-Jun-2021, the patient experienced CARDIAC ARREST (Cardiac arrest) (seriousness criteria death and medically significant). The patient died on 26-Jun-2021. The reported cause of death was Cardiac arrest. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 24-Jun-2021, Body temperature: 38 degree Celsius (High) 38. On 25-Jun-2021, Oxygen saturation: 83 (abnormal) 83. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. No treatment information was provided by the reporter. Action taken with mRNA-1273 in response to the event was not applicable. This is a case of death in a 74-year-old subject with a history of Encephalopathy and Cardiac pacemaker insertion, who died 5 days after receiving second dose of vaccine. Very limited information has been provided at this time.; Reporter''s Comments: Initial Report with additional information; Sender''s Comments: This is a case of death in a 74-year-old subject with a history of Encephalopathy and Cardiac pacemaker insertion, who died 5 days after receiving second dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: Cardiac arrest


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