BEUDAMED
    FDA Adverse Event Death Summary report: N

    CAPSUREFIX NOVUS

    MDR report key: 2021063 · Received March 16, 2011

    Report

    Report Number
    2649622-2011-03968
    Event Type
    Death
    Date Received
    March 16, 2011
    Date of Event
    September 26, 2007
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    DTB
    PMA / PMN Number
    P930039/S009
    Removal / Correction Number
    ASKU
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MN, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    THE INFORMATION SUBMITTED REFLECTS ALL RELEVANT DATA RECEIVED. IF ADDITIONAL RELEVANT INFORMATION IS RECEIVED, A SUPPLEMENTAL REPORT WILL BE SUBMITTED. ALL INFORMATION KNOWN WAS PROVIDED PER THE COMPLAINANT. THEREFORE, NO ATTEMPTS FOR ADDITIONAL INFORMATION WILL BE MADE. THE LEAD MODEL 6949 IS PART OF THE ADVISORY.

    Description of Event or Problem · 1

    AN ALLEGATION FROM AN ATTORNEY INDICATED THE "PATIENT HAS SUSTAINED SEVERE PHYSICAL INJURIES AND DEATH, SEVERE EMOTIONAL DISTRESS, AND ECONOMIC LOSSES AND CONSEQUENTIAL DAMAGES, AND ARE THEREFORE ENTITLED TO COMPENSATORY AND OTHER RELIEF ACCORDING TO PROOF." IT WAS ALSO REPORTED THAT THE PATIENT DIED ONE YEAR FROM SYSTEM IMPLANT. APPROXIMATELY THREE YEARS LATER, AN ALLEGATION FROM A SECOND ATTORNEY INDICATED THE PATIENT IMPLANTED WITH A RIGHT VENTRICULAR LEAD IS DECEASED AND NO FURTHER INFORMATION WAS PROVIDED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 CAPSUREFIX NOVUS IMPLANTABLE PACING LEAD DTB MEDTRONIC PUERTO RICO, INC. 5076 ASKU

    Patients

    Seq Age Sex Outcome Treatment
    1 57 YR Death