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From the 5/7/2021 release of VAERS data (an older release, current is 7/16/2021):

This is VAERS ID 1026499



Case Details

VAERS ID: 1026499 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-02-05
Onset:2021-02-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Body temperature increased, Cardio-respiratory arrest, Chills, Death, Pulse absent, Tremor, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Lactulose, Lasix, Megestrol Acetate, Metoprolol Tartrate, Spironolactone, Lasix, Vitamin B12, Rifaximin, Milk Thistle, Tramadol
Current Illness: Enterococcus UTI, acute on chronic systolic and diastolic heart failure
Preexisting Conditions: ,chronic kidney disease stage 3, cirrhosis, HTN, hypomagnesemia, hypothyroidism, neurocognitive disorder, hx of hepatic encephalopathy
Allergies: Carvedilol, Tizanidine, Augmentin, ACE inhibitors, Bees
Diagnostic Lab Data: None done at facility
CDC Split Type:

Write-up: Resident reviewed for incident. Resident received the second dose of the Moderna Covid-19 vaccine lot# 016M20A Exp 5/2/2021 on 2/5/2021 from clinic through pharmacy. Resident had her temp/O2 taken on AM shift and was 98.6/93%, beginning PM shift 98.4/95%. A few hours later noted that resident to have chills and was shaking RN assessment completed and vitals taken resident noted to have temp of 102.2, oxygen 95%, pulse 110. Resident alert and oriented at that time and talking to staff. Reported findings to APNP with order to send to ER. 911 called, residents brother updated. Upon EMT arrival RN went down to residents room with EMT and resident had an emesis as resident was getting cleaned up resident went unresponsive. Pulse noted to still be present at that time, resident did briefly respond to sternal rub and then went unresponsive again. Resident full code and EMT transferred to gurney and said that if they lost a pulse in route that they would transfer to hospital B instead of hospital A being the closest facility. RN called brother and gave update. Facility notified from Hospital that resident had passed away.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1026499


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