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From the 9/17/2021 release of VAERS data:

This is VAERS ID 936738

Case Details

VAERS ID: 936738 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Adenovirus test, Blood pressure immeasurable, Bordetella test negative, Chlamydia test negative, Death, Enterovirus test negative, Human metapneumovirus test, Human rhinovirus test, Hypopnoea, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative, Intensive care, Loss of consciousness, Mycoplasma test negative, Polymerase chain reaction, Radial pulse abnormal, Respiratory syncytial virus test negative, SARS-CoV-2 test negative, Staphylococcus test negative, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (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) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (narrow), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data: RSV, Bordetella Parapertussis, Bordetella Pertussis, Chlamydia pneumoniae, mycoplasma pneumoniae, Coronavirus, Adenovirus, Human metapneumovirus, human rhino/entero virus, influenza A/B, parainfluenza PCRs negative (NOT DETECTED) per 12/27/20 results COVID-19 PCR, Influenza A/B, and RSV PCRs negative (NOT DETECTED) per 1/4/21 results MRSA SURVL NARES DNA negative (NOT DETECTED) per 12/27/20, 12/28/20, & 1/5/21 results
CDC Split Type:

Write-up: loss of consciousness Narrative: Patient received COVID-19 vaccine dose #1 on 1/6/21 w/o complications. Per 1/6/21- 1/9/21 nursing notes, patient did not experience any injection site reactions, denied pain or tenderness at injection site, no dizziness, no n/v, remained afebrile. Around 1/9/21 @1810, patient became acutely nonresponsive after being helped to the edge of bed. Per nurses, he was previously awake/alert, talking and asymptomatic. Patient is DNR/DNI but facility rapid response emergency team called d/t patient''s sudden change of condition. Emergency team helped patient into lying position. Per 1/9/21 ICU emergency team note, patient appeared comfortable w/ no palpable radial pulse and had minimal shallow agonal breathing. Pulse ox 94%, HR in 60s per machine. BP unmeasurably low by BP cuffx3. Resident passed at 18:20 pm.

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