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

This is VAERS ID 995147



Case Details

VAERS ID: 995147 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-23
Onset:2021-01-20
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Chills, Death, Erythema, Fatigue, General physical health deterioration, Injection site pain, Laboratory test normal, Pain in extremity, Pyrexia, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Hypersensitivity (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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:
Allergies:
Diagnostic Lab Data: Lab tests after MODERNA COVID-19 vaccine: ALL NEGATIVE Orders for date: 01/19/2021 Test Urgency Status Lab NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/19/2021 12:43 Orders for date: 01/14/2021 Test Urgency Status Order NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/14/2021 15:59 Orders for date: 01/11/2021 Test Urgency Status Lab NASAL SWAB NASOPHARYNGEAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test complete 01/11/2021 12:27 Orders for date: 01/07/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/11/2021 17:01 Orders for date: 01/04/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/08/2021 07:34 Orders for date: 12/28/2020 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX COVID-19 DIAGNOSTIC PANEL (BIOFIRE) ROUTINE Test Complete 12/28/2020 13:58 PCR 20 1403 Most recent med list prior to patient''s death: INPT ACETAMINOPHEN 650 MG RTL SUPP (Status=Active) 650MG RCT FOUR TIMES A DAY AS NEEDED Fever. Give PR if unable to take PO ORDER LAST ACTION: 12/29/20 16:37 GIVEN ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3 ML INHALE 1 VIAL IN NEBULIZER BY ORAL INHALATION FOUR TIMES DAILY AS NEEDED COPD, MED HAS LARGE SUPPLY INPT BISADODYL 10MG RTL SUPP (Status=Active) 10MG RCT EVERY 72 HOURS AS NEEDED Constipation. Give if MOM ineffective ORDER LAST ACTION: 02/26/20 18:11 GIVEN INPT LORAZEPAM 2MG/ML INJ. 1 ML (Status=Active) 0.5MG(0.25 ML) SUBCUTANEOUSLY EVERY FOUR HOURS AS NEEDED End of life agitation or anxiety INPT MILK OF MAGNESIA 30 ML UD (Status=Active) 30ML BY MOUTH DAILY AS NEEDED CONSTIPATION ORDER LAST ACTION: 01/07/21 15:09 GIVEN INPT MORPHINE SO4 4MG/ML INJ PFS (Status=ACTIVE) 4MG/ML IV EVERY ONE HOUR AS NEEDED if needed for end of life restlessness, air hunger, pain. ORDER LAST ACTION: 01/19/21 11:15 GIVEN POLYETHYLENE GLYCOL 3350 ORAL PWDR TAKE 17 GM (ONE CAPFUL) BY MOUTH DAILY AS NEEDED constipation. MED HAS LARGE SUPPLY
CDC Split Type:

Write-up: Death Narrative: Patient received the first COVID-19 dose on 12/23. Afterwards, patient complained of localized pain on L deltoid area where the vaccine was administered; his temperature was 98.1 F. On 12/26-27, staff reported that patient appeared more fatigued than usual and was shivering on 12/27, which seized after blanket was given. On 12/28, patient presented with fever (Tmax 100.2 F) and acetaminophen was administered for alleviation of fever. ADR was reported for the fever on 12/29. Patient continued to decline and was placed back on hospice care on 12/29; on 12/30. the symptoms reported on nursing note include erythema and pain on whole L arm. Lidocaine was applied. Patient''s family and provider mutually agreed not to administer the second dose of vaccine. He continued to decline and was started on end-of-life care around 1/4 and passed on 1/20 1417.


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