BEUDAMED
    FDA Adverse Event Injury Summary report: N

    ALTIS KIT

    MDR report key: 6055684 · Received October 25, 2016

    Report

    Report Number
    2125050-2016-00327
    Event Type
    Injury
    Date Received
    October 25, 2016
    Date of Event
    September 26, 2013
    Report Date
    October 25, 2016
    Manufacturer
    COLOPLAST A/S
    Product Code
    PAH
    PMA / PMN Number
    K121562
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    ATTORNEY

    Narratives

    Additional Manufacturer Narrative · 1

    COLOPLAST HAS NOT BEEN PROVIDED ANY CORROBORATING EVIDENCE TO VERIFY THE INFORMATION CONTAINED IN THIS REPORT.

    Description of Event or Problem · 1

    AS REPORTED TO COLOPLAST, THOUGH NOT VERIFIED, THE PATIENT'S LEGAL REPRESENTATIVE STATED INCONTINENCE, INTRINSIC SPHINCTERIC DEFICIENCY

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    704375 ALTIS KIT SURGICAL MESH PAH COLOPLAST A/S 5196502400

    Patients

    Seq Age Sex Outcome Treatment
    1 64 YR Other