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From the 2/18/2021 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 1038635



Case Details

VAERS ID: 1038635 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: South Dakota  
Vaccinated:2021-02-05
Onset:2021-02-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Arrhythmia, Cardiac arrest, Death, Dementia, Fall, Hip arthroplasty, Hip fracture, Hypothyroidism
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (narrow), Acute central respiratory depression (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypothyroidism (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Arthritis (broad), Respiratory failure (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg enteric-coated q a.m. Plavix 75 mg po at bedtime Iron, Ferrex-150 25/1/150 tid with meals Folic acid 1 mg bid Metoprolol tartrate 25 mg bid MiraLAX 8.5 gm daily Synthroid 100 mcg a day Tamsulosin 0
Current Illness: A fall occurred on the day after vaccination; she fractured her hip in this fall. The physician reports she went into sudden and unexpected cardiac arrest during surgery and died. Patient had COVID-19 approx 11/06/2020. Possible urinary tract infection on admit for the fall
Preexisting Conditions: History of breast cancer (bilateral; patient is post-bilateral masectomy) Hypothyroid Dementia ("always confused about time and place") Recurrent urinary tract infections The patient was admitted August 2020 with suspected seizure but this was attributed to UTI and/or dementia) Hypertension Diffuse Arthritis Resident of assisted living facility
Allergies: Erythromycin Codeine
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient fell the day after receiving the Moderna COVID-19 vaccine. She broke her hip in this fall. During surgery to correct the broken hip, she went in to sudden and unexpected cardiac arrest. The anesthetist did not notice any ST changes or A fib; dysrhythmia was very unexpected. The patient had a DNR. She died at 13:00 on 02/07/2021. Causes of death are listed as 1. Cardiac Arrest 2. Recent hip fracture with hip placement 3. History of Breast Cancer 4. Hypothyroid and 5. Dementia


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210218&IDNUMBER=1038635

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