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From the 5/7/2021 release of VAERS data:

This is VAERS ID 893464



Case Details

VAERS ID: 893464 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Male  
Location: Rhode Island  
Vaccinated:2020-10-27
Onset:2020-10-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2020-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLULAVAL QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS 542MY / N/A LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-10-28
   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: Atrovent, baclofen, Famotidine, flonase, gabapentin, glycopyrrolate, lansoprazole, montelukast, oxcarbazepine, miralax, sennosides, tizanidine, Pediasure Peptide 1.5 nutritional formula PRN: tylenol, motrin, diastat
Current Illness: Increase in spasticity Elevated blood pressure
Preexisting Conditions: Spastic Quadriplegia, Feeding tube dependence (J Tube placed), malnutrition, sliding hiatal hernia, GERD, epilepsy, dysphagia, constipation, tracheobronhomalacia, visual impairment,
Allergies: Seasonal allergies No allergies to food, medications, products
Diagnostic Lab Data: Noe
CDC Split Type:

Write-up: Patient was put to bed at 10pm in his usual state of health. Parents found him unresponsive at 1am when they went to check on him per family routine. EMS was called. He was brought to the ER and was pronounced dead.


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