Inquest into the death of Mitchell Thomas
Deceased
Mitchell Thomas
Demographics
3y, male
Date of death
2023-06-01
Finding date
2026-06-05
Cause of death
Smoke inhalation with thermal inhalation injury and carbon monoxide poisoning
AI-generated summary
Mitchell Thomas, aged three, died in a public housing fire at Larapinta on 1 June 2023, from smoke inhalation. The fire was caused by electrical arcing in the roof space resulting from degraded insulation between two adjacent wires; the specific cause of degradation could not be determined, though rodent damage was considered most likely. A smoke alarm identified as needing replacement in January 2023 had not been replaced, potentially affecting early warning. The coroner's inquest examined electrical safety in public housing across Alice Springs and Tennant Creek. Audits revealed significant electrical defects in older properties, including earthing failures, cabling issues, and missing or non-functional smoke alarms. Key systemic failures identified included incomplete maintenance records, inadequate periodic electrical inspections, insufficient pest control, and poor coordination between fire and electrical safety investigators. The coroner made seven recommendations: regular periodic electrical inspections under AS/NZS 3019, Territory-wide pest control programs, improved maintenance tracking, inquest recommendation follow-up, and legislative reforms for electrical fire reporting and investigation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Electrical arcing in roof space from degraded wire insulation
- Rodent damage to electrical insulation (likely cause of degradation)
- Non-functional lounge room smoke alarm
- Failure to replace identified non-functional smoke alarms
- Inadequate electrical safety maintenance and inspection
- Incomplete housing maintenance records
Coroner's recommendations
- Housing is to complete Phase 2 of the audit and promptly remediate any issues identified
- Housing is to embed training of Housing Officers in safety feature checks using Mobile Inspection Tool and ensure electricians on callouts undertake routine safety checks recorded in Housing records
- Housing is to implement periodic inspections of all public housing in accordance with AS/NZS 3019 clauses 3, 4 and 5, with clause 5 inspections before properties reach 20 years of age, then every 10 years thereafter
- Housing is to implement a Territory-wide cyclical baiting program in all public housing
- Housing is to establish senior level responsibility and mechanism for ongoing tracking of coronial inquest recommendations and their implementation, and establishment and maintenance of a Register of Accidents and Incidents
- The Electrical Safety Regulator is to progress legislative reform to ensure suspected electrical fires are reported to it for investigation, similar to Victorian regime, and consider further changes to ensure legislation promotes best practice
- The Electrical Safety Regulator and Fire and Rescue are to develop a memorandum of understanding ensuring clear communication and that electrical fires are thoroughly investigated by persons with sufficient expertise, including provisions for external experts when necessary
Full text
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