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

This is VAERS ID 921572



Case Details

VAERS ID: 921572 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chills, Death, Fall, Hip fracture, Oxygen saturation decreased, Pain, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Fluticasone, Lasix, Omeprazole, Sucarafate, Ropinrole HCl
Current Illness: Heart Failure
Preexisting Conditions: Chronic Kidney Disease, Atherosclerotic Heart Disease
Allergies: Lisinopril, Losartan
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident had body aches, a low O2 sat and had chills starting on 12/30/20. He had stated that they had slightly improved. On 1/1/21 he sustained a fall with a diagnosis of a displaced hip fracture. On 1/2/21 during the NOC shift his O2 sat dropped again. He later went unresponsive and passed away.


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