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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1815096

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Case Details

VAERS ID: 1815096 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Female  
Location: Maryland  
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Anion gap increased, Aspartate aminotransferase increased, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood chloride normal, Blood creatinine normal, Blood glucose increased, Blood potassium decreased, Blood sodium normal, Blood urea normal, Carbon dioxide decreased, Cardioversion, Death, Dizziness, Dyspnoea, Feeling abnormal, Full blood count, Haematocrit normal, Haemoglobin normal, Loss of consciousness, Metabolic function test, Nausea, Platelet count normal, Resuscitation, SARS-CoV-2 test negative, Supraventricular tachycardia, Unresponsive to stimuli, Vomiting, White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Hypokalaemia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-27
   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:
Current Illness: None
Preexisting Conditions: Asthma
Allergies: None known
Diagnostic Lab Data: Initial CBC with WBC 6.59, Hg 12.2, HCT 35.3, platelets 278. CMP with CO2 18, anion gap 22, glucose 270, Na 139, K 2.8, Cl 103, BUN 16, Creatinine 0.77, Albumin 3.4, ALK 97, AST 152, ALT 32, bilirubin 0.3. COVID PCR not detected.
CDC Split Type:

Write-up: Patient received first COVID vaccine on 7/11/21. She was well until 7/26/21 when she developed nausea, vomiting, shortness of breath and dizziness. At approximately 04:00 on 7/27/21, she woke up feeling poorly, went into the bathroom and then lost consciousness. EMS was called, she was in a tachycardia at 180 bpm, BP 88/64, unresponsive. EMS report states she was "in SVT and cardioverted at 30J then 70 J. Still in SVT but becoming more alert. HR 165 bpm, sats 98%." In ED, she was felt to be in ventricular tachycardia, She received attempted resuscitation with multiple rounds of CPR including chest compressions, defibrillation for reported ventricular fibrillation, and medications. She was unable to be resuscitated and death was pronounced in the ED. Autopsy is pending.

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