I'm sorry to read about your loss, and I applaud your initiative. I believe a large part of the reason things like this happen is because the solution is so enormously complex. Developing the software tech (a undertaking in itself) is one thing. Also required: updating/changing existing regulations (slow & bureaucratic), training & support, budget approvals, politics, not to mention the doctor's decision-making process and communication responsibilities...the list goes on and on!

Eventually we will have a better system. Unfortunately this is likely to be a very slow, gradual process, which I hope to witness over the course of the next few decades. In this particular case, software tech could have served as a communication platform to reduce the chances of doctor miscommunication and/or overlooking a patient's varying conditions. Generally speaking (and by my personal experience), doctors seem to be notoriously bad about communicating the overall picture to responsible parties, at least here in the U.S. Each doctor takes care of his/her own "backyard" before dashing off to the next patient. I recognize that this is by no means solely the fault of the doctor. It's the system!

Again, good on you for wanting to be part of the solution.