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From the 11/12/2021 release of VAERS data:

This is VAERS ID 419564

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Case Details

VAERS ID: 419564 (history)  
Form: Version 1.0  
Age: 5.0  
Sex: Male  
Location: Vermont  
Vaccinated:2011-02-07
Onset:0000-00-00
Submitted: 2011-03-25
Entered: 2011-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPV: DTAP + IPV (KINRIX) / GLAXOSMITHKLINE BIOLOGICALS AC20B172AA / 1 RA / UN
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1272Z / 1 RA / UN

Administered by: Private       Purchased by: Public
Symptoms: Condition aggravated, Death, Epilepsy, Status epilepticus, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-02-08
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin B; LAMICTAL; KEPPRA; TOPAMAX
Current Illness: None
Preexisting Conditions: Epilepsy; Right hemiparesis; GERD; Strabismus; Cerebral Palsy
Allergies:
Diagnostic Lab Data: Known left middle cerebral artery infarct with right hemiplegia and epilepsy.
CDC Split Type:

Write-up: DTaP/IPV and VARIVAX given at 14:30 on 2/7/11 as health care maintenance. Patient found unresponsive with vomit in bed around 6 am on 2/8/11. Pronounced deceased on arrival to the ED on 2/8/11. Presumed cause of death is status epilepticus in this patient with known and worsening epilepsy. Medical Examiner involved, and no autopsy performed.


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