MAUDE Adverse Event Report: DEPUY INT'L LTD. 8010379 C STEM VOID CENTALIZER 12 DM; HIP MISCELLANEOUS : CEMENT CENTRALIZER/PLUG

Catalog Number	961212500
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Death (1802); Pain (1994)
Type of Reportable Event	Death
Additional Manufacturer Narrative
(b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.Date of death is currently unknown.Initial reporter occupation: non-healthcare professional "patient family member".
Event or Problem Description
Patient communication received.A daughter of a patient from (b)(6), called up regarding the hip replacement compensation, in reference to the news she read in the newspaper.She said that her mother had undergone a surgery of total hip replacement in the year 2014 at a hospital in (b)(6), and in (b)(6) 2015 her mother passed away.Thus, she wants to know the procedure to claim the compensation amount.
Additional Manufacturer Narrative
Product complaint : (b)(4).Investigation summary : no device associated with this report was received for examination.Depuy considers the investigation closed at this time.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.If information is obtained that was not available for the initial medwatch , a follow-up medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: C STEM VOID CENTALIZER 12 DM
• Common Device Name: HIP MISCELLANEOUS : CEMENT CENTRALIZER/PLUG
• Manufacturer (Section D): DEPUY INT'L LTD. 8010379; st. anthony's rd; leeds LS11 8 DT; UK LS11 8 DT
• MDR Report Key: 8314625
• Report Number: 1818910-2019-83467
• Device Sequence Number: 13468342
• Product Code: JDI
• UDI-Device Identifier: 10603295235736
• UDI-Public: 10603295235736
• Combination Product (Y/N): N
• Initial Reporter Country: IN
• PMA/510(K) Number: K013350
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Reporter Type: Manufacturer
• Report Source: consumer,foreign
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 01/08/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Catalogue Number: 961212500
• Device Lot Number: 4727177
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 01/08/2019
• Supplement Date Received by Manufacturer: 03/20/2019
• Initial Report FDA Received Date: 02/07/2019
• Supplement Report FDA Received Date: 03/25/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Death; Other