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From the 10/15/2021 release of VAERS data:

This is VAERS ID 949630



Case Details

VAERS ID: 949630 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-01-02
Onset:2021-01-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood pressure decreased, Death, Hypophagia, Hypotension, Hypoxia, Oxygen therapy, Tachypnoea
SMQs:, Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Senna-S, cranberry pills
Current Illness: Redness to left foot about 1 week prior to vaccination that resolved a few days prior
Preexisting Conditions: Advanced Dementia, Seizure disorder, CAD, prior stroke, HTN
Allergies: Simvastatin
Diagnostic Lab Data: None as she was under hospice care
CDC Split Type:

Write-up: This patient has been under hospice care for over 2 years at the nursing home. She has had a steady decline with gradual weight loss. She was totally dependent in her care needs. She received the vaccine on 1/2/2021 as part of the facility vaccination campaign. No adverse events noted initially. On 1/3/2021 at 6:06 pm, she was noted on vital sign checks (done every 4 hours for first 72 hours after vaccination) with BP 64/52 but otherwise asymptomatic. Subsequent BP improved. On 1/4/2021 at 4:45 am, pt found with respiratory rate of 30 with otherwise normal vital signs. Tachypnea persisted, so she received liquid morphine 2.5 mg without improvement. Supplemental oxygen was applied. Tachypnea persisted. She had poor oral intake after that point had persistent tachypnea and worsening hypoxemia despite clear lungs on exam. She remained under hospice care and comfort measures were continued. No blood testing or imaging tests were done. She required increasing amounts of oxygen, became hypotensive, and died peacefully on 1/8/2021 at 7:45 pm.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=949630

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