A Melbourne mother who killed one of her twin baby girls seemed caring and attentive towards them just two days before the death.
Maternal and child health nurse Roslyn Monagle, who has worked in the field for 37 years, examined the babies on April 24, 2012.
She referred the family to their GP after noticing a small bruise and scratch on one of the twins, but they never made the appointment because the other twin died two days later.
An autopsy found traumatic injuries to the baby's brain, body and ribs that were not all accidental, and had been inflicted at different times.
The twins' mother pleaded guilty last year to infanticide - an offence that applies when a mother kills her infant while in a disturbed state of mind.
She also pleaded guilty to a count of recklessly causing serious injury to the other twin, and was sentenced to a 12-month community corrections order.
An inquest is being held to examine the role of healthcare providers before the death.
Ms Monagle said the marks on the other twin had raised a "red flag" at the appointment, but she did not believe they were intentional.
There were no obvious injuries on the girl who died.
"I only knew them as caring, loving, protective parents," Ms Monagle said of the family at the Coroners Court of Victoria on Thursday.
Another nurse, Anne Kingston, had seen the babies about a month earlier and asked questions about bruises on both of them.
The girls' mother said they slept close together in their cot and might have hit each other while flailing their arms around.
Ms Kingston accepted that explanation, but told the mother to alter the sleeping arrangements.
Her notes about the bruises were not read by Ms Monagle at the babies' appointment four weeks later.
Ms Monagle was also not aware that the mother had recently returned a high score on a post natal depression screen test, carried out at a different health service.
She told the court she would have admitted the family to hospital immediately if she had all the available information.
The inquest continues.
