Despite brave efforts to save him, Mitchell Thomas died in a blaze at his home in the Alice Springs suburb of Larapinta on June 1, 2023.
Initial investigations identified the possible cause as an electrical fault in cabling in the ceiling, with timber beams catching fire and filling the house with smoke.
Mitchell was being looked after at the social housing property by his 16-year-old uncle Bradley after his mother left for an appointment, leaving all the house doors locked.
A triple-zero call was made by neighbour Sarah Larson, telling the operator smoke was coming from the home and that her husband was trying to get the locked doors open.
Stephen Greenfield, who was driving past, stopped to help pull a window frame out of the burning house to save the uncle, who told them Mitchell was inside.
Police arrived and kicked down a door but the heat was so intense they could not find Mitchell and had to retreat.
On arrival, firefighters in protective gear entered the house and found Mitchell unresponsive in a bedroom.
Frantic efforts were made at the scene and at Alice Springs Hospital but he could not be revived.
An autopsy report identified the cause of death as smoke inhalation.
The house was owned by the Northern Territory government as part of its social housing stock of over 10,000 dwellings.
The non-compliant wiring found in the Larapinta house gave rise to concerns there could be a wider problem in the electrical wiring of social housing premises.
Because of that concern, the coroner's office suggested to relevant government departments that an audit be conducted to investigate if that was the case.
An audit of around 600 social housing dwellings found 21 per cent had one or more expired smoke detectors, 10 per cent had a major earthings system fault, and 58 per cent required immediate remediation work.
In her findings released on Friday, NT Coroner Elisabeth Armitage found the fire was caused by electrical arcing in the roof space of the home triggered by insulation degradation around two adjacent wires.
It was not possible to say if the insulation degradation was caused by mechanical, chemical or environmental damage or by the action of rodents, she said, noting rodent damage was common.
The coroner found that despite a housing officer's inspection report in January 2023 recommending new smoke alarms, that was not communicated to maintenance staff and there was no evidence they were replaced.
"This is a most unsatisfactory position," the coroner said.
"No doubt, this weighs very heavily on government which, as owner, is responsible for providing safe and habitable premises and is responsible for maintenance and repairs."
She recommended the NT government's housing department implement a program of periodic inspections of all public housing before a property reaches 20 years of age and then every 10 years to ensure electrical safety.
The department should also embed in policy the training of housing officers to conduct checks of safety features, including smoke alarms, and electricians on call-outs should undertake routine safety checks.
A territory-wide recurring rodent baiting program should also be implemented in all public housing properties.
The Electrical Safety Regulator and Fire and Rescue should also ensure clear communication between them so all electrical fires were thoroughly investigated by experts in their fields, the coroner said.
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