While there has been a dramatic decline in the incidence of SUDI in NSW, SUDI's continue to make up a large proportion of potentially preventable deaths in children younger than 18 years. During the period 2000 to 2002, there was an average of 62 SUDI's in NSW. The Child Death Review Team (CDRT) examined these incidences of SUDI in order to fuse existing knowledge of unsafe sleeping environments; to determine parental practices that may contribute to SUDI; to describe current policy and practice in NSW regarding the response to these types of deaths; and to identify the proportion of SUDI that are the result of assault or neglect. The methodology involved a comprehensive literature review examining the current research and international practices and policies related to SUDI; an audit of key information regarding SUDI in NSW; an analysis of NSW policies and guidelines regarding SUDI; an analysis of worker practices; an investigation of parental practices in terms of modifiable risk factors; and an analysis of SUDI resulting from assaults or neglect. The findings indicate that the NSW data collection process should be improved by standardizing documents and adopting international SUDI practice guidelines and protocols. A number of limitations were found regarding current policies and guidelines in NSW, including uncoordinated monitoring and research activities. It was also found that many workers lacked adequate training and experience and that the more information parents had regarding risk factors for SUDI, the better prepared they were regarding proper care for their infants. Several recommendations are extended, such as the need for informational campaigns to reach a wider audience and to specifically target high-risk groups and the need for pathologists to follow a uniform protocol and make consistent decisions. Tables, figures, references, appendixes