Finding into death of Nicky Kudrin

IN THE CORONERS COURT COR 2021 003580 OF VICTORIA AT MELBOURNE FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Inquest into the death of Nicky Kudrin Delivered On: 31 January 2025 Delivered At: Melbourne Coroners Court Hearing Date: 31 January 2025 Findings of: Coroner John Olle Representation Lindsay Spence, In-House Legal Service Coroners Court of Victoria Counsel Assisting the Coroner Jess Syrjanen, Senior Coroner’s Solicitor Coroners Court of Victoria Chief Commissioner of Tarryn Jeffery, Senior Solicitor Police Victorian Government Solicitor’s Office

Table of Contents Examination of Victoria Police’s response on 7 July 2021 and whether it was appropriate and in

BACKGROUND

1. Nicky Kudrin (‘Mr Kudrin’), born on 1 July 1961, was 60 years old at the time of his death which occurred on 7 July 2021 during a police operation to arrest him for alleged family violence offending. Mr Kudrin was found deceased within the residence of his exwife after sustaining a self-inflicted gunshot wound from a homemade firearm. At the time of his death, Mr Kudrin lived within the suburb of Hillside, having moved in with his next-door neighbour following the breakdown of his marriage and subsequent sale of the family home.

2. Mr Kudrin met his wife to be, Valentina, in 1991 when she was 24 years old, and he was 29-30 years old. Approximately six months after meeting they started dating and then lived together for the following eight (8) years prior to marrying in 1999. Following their marriage, they lived in St Albans prior to moving to West Meadows and finally settling in Hillside.

3. Their relationship deteriorated and they separated around 2019 approximately two years prior to Mr Kudrin’s death, however lived together at the Hillside address for approximately 12 months prior to the sale of the family home. Valentina indicates that ‘during the marriage, there had never been any domestic violence, there had never been threats of violence and he never mentioned suicide or had any suicidal thoughts. As soon as we were separated, this changed … … he was very moody, there were days where he was reasonable and we could have a conversation, and then other days he would be up, wanting to fight, he was manic’. Following the sale of the family home, Valentina moved to Caroline Springs whilst Mr Kudrin moved in with the next-door neighbours at Hillside.

Mr Kudrin reportedly did not want to sell the family home and began to damage items in the house and graffitiing the walls, in order to make it more difficult to sell.

4. On 28 October 2019, Valentina located petrol cans throughout the house, became panicked, and called her employer who in turn, called the police. Police attended the home and conveyed Mr Kudrin to Sunshine Hospital under section 351 of the Mental Health Act 2014 (Vic) after he expressed ‘suicidal thoughts’, including a plan to set himself on fire. Police completed a family violence risk assessment (FVR L17), which triggered referrals to specialist family violence services, however the services were unable to contact either party.

5. While in hospital, Mr Kudrin disclosed ongoing depressive symptoms since the separation and noted he was consuming a bottle of whiskey per day. He denied ongoing suicidal ideation and staff documented that he ‘uses suicidal threats to communicate his distress in a maladaptive way’. Staff also spoke with Valentina, who explained that Mr Kudrin had been increasingly agitated recently, but had not been violent towards her.

She also agreed to the hospital’s plan to discharge Mr Kudrin home. When he returned home that evening, Mr Kudrin admitted to Valentina that he had planned to burn the house down.

6. Following the October 2019 incident, police attempted to contact Valentina regarding a possible intervention order, however she did not return their calls, so they took no further action.

7. In April 2020, the family home was sold. After a few months of living with his neighbour, Mr Kudrin moved out and stayed with another friend, and at one point, lived in his van.

After selling their house, Mr Kudrin reportedly flooded Valentina’s phone with aggressive text messages, so she blocked his number.

8. On 26 November 2020, Mr Kudrin attended Valentina’s home and emailed her from outside the house. He stated that he was going to set himself on fire so that she could ‘watch him burn’. When Valentina returned home, she observed her security door handle was broken. The next day, Valentina applied for a family violence intervention order (FVIO) via the Magistrates’ Court of Victoria (MCV). In her application, she stated that Mr Kudrin was keeping her under surveillance, had attended her home two days earlier ‘screaming and ranting’, regularly attended her home uninvited and waited for her; if she did not arrive, he would send her aggressive emails and text messages.

9. The Sunshine Magistrates’ Court issued an interim FVIO with full conditions, preventing any communication or contact with Valentina. The case was adjourned to 23 June 2021.

Police attempted to locate Mr Kudrin to serve the interim FVIO, however were unsuccessful in locating him. Mr Kudrin continued to send Valentina abusive and threatening emails, attended her address uninvited and damaged her property.

10. On 9 January 2021, Mr Kudrin attended Valentina’s home. When she asked him to leave, he became verbally abusive and walked towards her in a manner which indicated he intended to choke her, then drove his car into her garage door, before leaving. Valentina called the police, who searched the area, but were unable to locate Mr Kudrin. Valentina provided a statement to police in which she noted that she was ‘always scared and checking my mirrors now to make sure he isn’t around’. Police commenced a criminal investigation and completed another FVR L17, which initiated new specialist family violence referrals. However, the men’s referral service did not contact Mr Kudrin as police had been unable to speak with him about the referral and Valentina did not answer the calls from the women’s service.

11. On 21 January 2021, Victoria Police returned the unserved FVIO to Sunshine Magistrates’ Court and advised they had been unable to serve it on Mr Kudrin.

12. On 16 May 2021, Mr Kudrin attended Valentina’s home, banged on her door and verbally abused her from the street. Valentina heard Mr Kudrin state that he was going to blow himself up, so she called police. Mr Kudrin decamped before police were able to arrive, and they were unable to locate him during a search of the area. Police completed another FVR L17 which triggered further specialist family violence referrals. However, as per the previous referrals, the service did not contact Mr Kudrin as police had not spoken with him and Valentina did not answer the calls from the women’s service.

13. On 23 June 2021, a magistrate at the Sunshine Magistrates’ Court struck out Valentina’s application for an FVIO, as she did not attend court.

14. In the months prior to his death, Mr Kudrin continued to send frequent abusive and threatening emails, sometimes more than once a day. About two weeks before the fatal incident, Mr Kudrin attended Valentina’s home and took one of her dogs. He returned on 7 July 2021 to return the dog, forced his way into the property, assaulted Valentina and damaged property, resulting in a police operation to arrest him and his subsequent death, the circumstances which are detailed later within this Finding.

CORONIAL INVESTIGATION Jurisdiction

15. Mr Kudrin’s death constituted a ‘reportable death’ pursuant to s 4(2)(c) of the Coroners Act 2008 (Vic) (‘Coroners Act’), as his death occurred in Victoria and immediately before his death, he was a person placed in custody or care (being a person who a police officer is attempting to take into custody or who is dying from injuries sustained when a police officer attempted to take the person into custody). Accordingly, pursuant to s 52(2)(b) of the Coroners Act, an inquest into his death is mandatory.

Purpose of the Coronial jurisdiction

16. The jurisdiction of the Coroners Court of Victoria (‘Coroners Court’) is inquisitorial.1 The purpose of a coronial investigation is to independently investigate a reportable death to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which the death occurred.2

17. The cause of death refers to the medical cause of death, incorporating where possible, the mode or mechanism of death.

18. The circumstances in which the death occurred refers to the context or background and surrounding circumstances of the death. It is confined to those circumstances that are sufficiently proximate and causally relevant to the death.

19. The broader purpose of coronial investigations is to contribute to a reduction in the number of preventable deaths, both through the observations made in the investigation findings and by the making of recommendations by coroners. This is generally referred to as the prevention role. Coroners are empowered to advance their prevention role by: a. reporting to the Attorney-General on a death; b. commenting on any matter connected with the death they have investigated, including matters of public health or safety and the administration of justice; and c. making recommendations to any Minister or public statutory authority or entity on any matter connected with the death, including public health or safety or the administration of justice.3 1 Section 89(4) Coroners Act.

2 Preamble and s 67 Coroners Act.

3 Sections 67(3), 72(1) and (2) of the Coroners Act.

20. It is important to stress that coroners are not empowered to determine the civil or criminal liability arising from the investigation of a reportable death and are specifically prohibited from including a finding or comment or any statement that a person is, or may be, guilty of an offence.4 It is not the role of the coroner to lay or apportion blame, but to establish the facts.5 However, a coroner may include a statement relating to a notification to the Director of Public Prosecutions if they believe an indictable offence may have been committed in connection with the death.6 Standard of proof

21. All coronial findings must be made based on proof of relevant facts on the balance of probabilities.7 The strength of evidence necessary to prove relevant facts varies according to the nature of the facts and the circumstances in which they are sought to be proved.8

22. In determining these matters, I am guided by the principles enunciated in Briginshaw v Briginshaw.9 The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals or entities, unless the evidence provides a comfortable level of satisfaction that they caused or contributed to the death.

23. Proof of facts underpinning a finding that would, or may, have an extremely deleterious effect on a party’s character, reputation or employment prospects demands a weight of evidence commensurate with the gravity of the facts sought to be proved.10 Facts should not be considered to have been proven on the balance of probabilities by inexact proofs, indefinite testimony or indirect inferences. Rather, such proof should be the result of clear, cogent or strict proof in the context of a presumption of innocence.11

24. Whilst an inquest was mandatory in respect of Mr Kudrin’s passing, in the circumstances I considered it appropriate to hold a summary inquest which was held on 31 January

25. The individual witnesses who provided statements in the inquest brief were not required to give evidence at inquest as, after carefully considering all the material within 4 Section 69(1) of the Coroners Act.

5 Keown v Khan (1999) 1 VR 69.

6 See ss 69(2) and 49(1) of the Coroners Act.

7 Re State Coroner; ex parte Minister for Health (2009) 261 ALR 152.

8 Qantas Airways Limited v Gama (2008) 167 FCR 537 at [139] per Branson J (noting that His Honour was referring to the correct approach to the standard of proof in a civil proceeding in the Federal Court with reference to s 140 of the Evidence Act 1995 (Cth); Neat Holdings Pty Ltd v Karajan Holdings Pty Ltd (1992) 67 ALJR 170 at 170-171 per Mason CJ, Brennan, Deane and Gaudron

JJ.

9 (1938) 60 CLR 336.

10 Anderson v Blashki [1993] 2 VR 89, following Briginshaw v Briginshaw (1938) 60 CLR 336.

11 Briginshaw v Briginshaw (1938) 60 CLR 336 at pp 362-3 per Dixon J.

the brief, I was satisfied that there were no significant factual disputes which required the calling of viva-voce evidence. Accordingly, I was satisfied that I was able to discharge my statutory functions and make the findings required under section 67 of the Coroners Act. All interested parties who appeared at inquest were given an opportunity to make submissions in relation to the evidence, including any proposed comments and recommendations.

25. This finding draws on the totality of the material obtained in the coronial investigation of Mr Kudrin’s death: the coronial brief prepared by Detective Senior Sergeant Simon Florence of the Victoria Police Homicide Squad, further material obtained by the Court; the transcript of the proceedings; exhibits tendered at the inquest (which in this case, was the inquest brief v2.0 [as at 21 January 2025]) and closing submissions of counsel.

26. In writing this finding, I do not purport to summarise all the material evidence but refer to it only in such detail as appears warranted by its forensic significance and the interests of narrative clarity. It should not be inferred from the absence of reference to any aspect of the evidence that it has not been considered.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased: s 67(1)(a) of the Coroners Act

27. On 16 July 2021, Mr Kudrin was identified by DNA comparison as per the Determination by Coroner of Identity of Deceased. Mr Kudrin’s identity was not in dispute and required no further investigation.

Cause of death: s 67(1)(b) of the Coroners Act

28. On 9 July 2021 Dr Melanie Archer, Forensic Pathologist at the Victorian Institute of Forensic Medicine conducted an autopsy on Mr Kudrin Kudrin’s body and provided a written report of her findings dated 18 November 2021.

29. The post-mortem examination identified a gunshot entrance wound under the chin absent an exit wound, causing unsurvivable brain injury. The gunshot had caused destruction of the facial skeleton and anterior cranial fossa with a large number of shotgun pellets recovered internally. The shotgun cartridge wad was also retrieved from the base of the skull. The main wound track was directed upwards and backwards, approximately in the midline.

30. The post-mortem examination also revealed that the deceased suffered from cardiomegaly, focally severe coronary artery atherosclerosis in the distal right coronary artery and left ventricular hypertrophy although this was not causal to death due to the fatal nature of the gunshot injury.

31. Dr Archer opined that ‘determination of the range of fire in gunshot cases is challenging, and distance estimation requires test firing of the weapon in question. This may be especially true given that the weapon was homemade. However, a pathological range of fire comprising the categories of “contact/near contact”, “intermediate” and “distant” can be made on the basis of wound characteristics. The entrance wound in this case is favoured to be contact/near contact due to the retrieval of wadding from the base of the skull. The presence of lacerations at the edges of the mouth from intra-oral gas expansion associated with the weapon discharge also support this notion. However, the importance of test firing to determine range of fire must be emphasised’.

32. Post-mortem toxicology identified the presence of methylamphetamine (and its metabolite amphetamine) and diazepam.

33. Dr Archer determined the cause of death to be I(a) GUNSHOT WOUND TO THE HEAD.

34. I accept Dr Archer’s opinion.

Circumstances in which the death occurred: s 67(1)(c) of the Coroners Act Wednesday 7 July 2021

35. On Wednesday 7 July 2021, approximately 9.36pm, Valentina was at home within her residence at St Georges Way, Caroline Springs when her ex-husband attended the residence. Earlier that day there had been emails exchanged and Valentina had been expecting Mr Kudrin to attend her premises for the sole purpose of dropping her dog off.

36. Following Mr Kudrin ringing the front doorbell, Valentina opened the front door enough so that the dog was able to enter. Mr Kudrin subsequently forced the door wide open with Valentina responding saying ‘I didn’t invite you in, go’. Mr Kudrin ignored Valentina despite her repeatedly telling him to leave and then entered the house and sat down on a couch near the front door and started calling out the name of their other dog. This initial interaction at the front door was captured on the doorbell video camera.

37. Mr Kudrin ‘then started rambling about why we split up and all my affairs and all my boyfriends and all my friends’. Valentina kept telling Mr Kudrin to leave and finally when he refused said ‘if you don’t go I will call the police’ to which Mr Kudrin replied ‘Yeh call the police’. Valentina then walked upstairs to the main bedroom to get her mobile phone with Mr Kudrin following. Valentina shut the bedroom door and tried to hold it closed however Mr Kudrin kicked the door open despite Valentina’s attempts and entered the bedroom, pushing Valentina to the ground.

38. Mr Kudrin then stood over Valentina and hit her repeatedly to the back of the head with a closed fist saying ‘I am going to kill you … … I’m going to kill myself, I am going to blow my brains out’. Mr Kudrin’s behaviour caused Valentina to fear for her life and she was fearful that Mr Kudrin was going to kill her. Mr Kudrin then started smashing items in the bedroom including the television on the dresser and Valentina’s phone on the bedside table before throwing the mobile on the floor and stomping on it, saying ‘I am going to wreck the joint, I am going to wreck everything in the place’.

39. Valentina got up off the floor however felt dizzy, and that she was going to throw up, and therefore went and sat in the bedroom ensuite. Mr Kudrin followed and without warning took what Valentina described as a ‘metal tube’ from his pocket that was silver in colour. Mr Kudrin then pointed the metal tube at Valentina saying ‘do you want me to use this on you?’ before pointing the metal tube at himself saying ‘I’m going to blow my brains out’.

40. Valentina ‘knew that it was a firearm. I knew he was capable of making a firearm, and when he pointed it at me, I thought he was going to kill me. He said he was going to blow his brains out, but he pointed it at me, so I thought he was just going to kill me’.

41. Mr Kudrin then turned away from Valentina and started smashing further items with Valentina then running past Mr Kudrin and out of the main bedroom. Valentina ran downstairs and out of the front door with Mr Kudrin yelling at her to come back however she ignored his demands. Five seconds later Mr Kudrin exited the front door yelling ‘Come here … … Come here … … I’m going to kill myself’ before exiting the front gate however Mr Kudrin did not chase after Valentina. He opened the door of his vehicle that was parked at the front of the premises before returning inside his ex-wife’s residence approximately 10.17pm.

42. Valentina ran to a neighbouring property and rang the doorbell of that house. The male occupant answered the door and observed that Valentina was extremely distressed and sobbing. He then let Valentina inside and closed the front door with the female occupant of that house contacting triple zero once they were able to understand from Valentina what had just occurred.

43. At 10.19pm the Emergency Services Telecommunications Authority (ESTA as it then was) received a triple zero call from the female occupant of that premises advising ‘so we had our neighbour who just walk in, she say that her ex-husband is – went to her home, he smashing everything. She’s also not sure if he may have been holding firearm or something but he was holding something in his hand. Yes, she’s now safe in my house. She’s quite distressed’. It was subsequently confirmed that Valentina had been assaulted by being pushed to the ground and punched to the back of the head. In respect of the apparent firearm, Valentina indicated to the ESTA call-taker that ‘he had something steel in his hand, so it could be, but I don’t know’

44. That evening Constable Head and First Constable Magill were tasked to the Melton nightshift divisional van (callsign Melton 310) with their shift commencing at 10.00pm. At 10.22pm a job was broadcast via D24 to attend the premises in St Georges Avenue, Caroline Springs in relation to a family violence related assault that had just occurred.

At that time the D24 Police Dispatcher broadcast in respect of a possible firearm only that ‘male had something metal in his hand … … not known what it was’.

45. At 10.26pm Melton 310 immediately diverted from their current taskings and whilst enroute, Constable Head called the neighbour who had contacted triple zero and enquired whether Mr Kudrin was still next door. The occupants indicated that they had no way of knowing whether he was still at the address, but that he was last seen there approximately ten minutes earlier.

46. Approximately 10.30pm Constable Head and First Constable Magill arrived at the neighbouring property that was approximately 70 metres down the street and spoke with Valentina as well as the neighbours that had assisted. That interaction was recorded on Constable Head’s body worn camera (‘BWC’). Valentina disclosed to the Officers what had just occurred, including that she believed Mr Kudrin was in possession of a silver tube that she thought may have been a firearm and had threatened to kill her.

This information was subsequently broadcast over D24 at 10.36pm that Mr Kudrin was possibly in possession of a firearm.

47. At 10.43pm, in response to the broadcast, numerous Specialist Units were informed of the events unfolding, including both the Police Canine Unit and the Critical Incident Response Team (CIRT). The Divisional Patrol Supervisor Senior Sergeant Dolman (Melton 265) also acknowledged at 10.46pm that he was aware of and following the job.

48. That evening A/Sergeant Sekoa and First Constable Gillen were tasked to the Melton night-shift Patrol Supervisor divisional van (callsign Melton 251) and immediately responded to the incident, arriving in St Georges Avenue at 10.53pm.

49. Prior to their arrival A/Sergeant Sekoa requested D24 to conduct checks in respect of Mr Kudrin and the address for firearms registered/involvements, past and current family violence incidents and it was confirmed that Mr Kudrin had no registered firearms and no firearms registered to that address.

50. In respect of Mr Kudrin’s LEAP Person History Report, the following limited history became available: a) Person Warning Flag: Suicide/Self Injury; b) Perpetrator in respect of three (3) separate FV incidents dated 28 October 2019, 9 January 2021 and 16 May 2021; c) Lapsed/Struck Out Intervention Order dated 27 November 2020; d) Section 351 Mental Disorder Transfer dated 28 October 2019 (same date as the initial FV incident).

51. A/Sergeant Sekoa also confirmed that Constable Head and First Constable Magill were approximately 100 metres from the last known location of Mr Kudrin, given he was potentially armed with a firearm. Upon arrival A/Sergeant Sekoa sought a briefing from First Constable Magill, especially in respect of the possible firearm that Mr Kudrin had in his possession. Whilst this briefing was occurring in the street, First Constable Gillen heard a male voice yelling out and commenced a conversation with Mr Kudrin.

52. At the time First Constable Gillen estimated that he was eighty metres from the address.

He saw Mr Kudrin standing on the front balcony of his ex-wife’s residence in St Georges Avenue however ‘I couldn’t see Mr Kudrin as there was no balcony light on at the time. I had a rough idea on where he was standing due to a small light that I could see at about chest height, it looked as though it could have been a mobile phone screen turning on and off’.

53. First Constable Gillen then asked Mr Kudrin whether there were any other persons inside the residence to which he replied ‘no, just my dogs’. A conversation then ensued with First Constable Gillen attempting to build rapport with Mr Kudrin, talking about a range of matters including his Jack Russell terriers. During the conversation First Constable Gillen asked Mr Kudrin whether he had any weapons that could harm him or anyone else with Mr Kudrin replying ‘Yeah I do, I have plenty here, I am holding a gun I made up to my neck right now’. First Constable Gillen responded saying ‘I don’t want you to hurt yourself, lets talk about what’s going on today, can you turn the light on mate so I can see you?’ however Mr Kudrin replied indicating that he wasn’t going to.

54. Mr Kudrin then indicated that ‘all I want to do is talk with my wife, she is my world, let me talk with her’ however First Constable Gillen responded ‘mate we can’t do that right, I’m here for you, I want to help’. First Constable Gillen continued to talk with Mr Kudrin about the relationship with his wife however Mr Kudrin ‘kept rambling on about how conniving and manipulative his wife could be and that was the reason for the situation he was in. The conversation got to a point where talking about her was making him angry, I could tell by the tone in his voice’ and First Constable Gillen decided to change the subject.

55. He then discussed with Mr Kudrin his past employment, finding out that he was a carpenter by trade for the past forty years, with Mr Kudrin telling him that he had dreams of fixing a van and decking it out so that he could travel around Australia with his wife. Mr Kudrin then brought up that he wanted to talk with his wife saying ‘it’s going to end tonight, I am not leaving here’. At one point during the conversation First Constable Gillen recalls Mr Kudrin saying ‘I know this isn’t going to end well, you’re here to arrest me and take me to gaol, I know it never ends well for the male’.

56. First Constable Gillen then enquired whether Mr Kudrin had any family members close by with Mr Kudrin indicating that he had family in St Albans, including his mother. Again, First Constable Gillen attempted to divert the conversation to unrelated topics however Mr Kudrin continued to request that he wanted to see his wife.

57. At 10.56pm following Mr Kudrin’s disclosures to First Constable Gillen that he was holding a firearm up to his neck, intended to use it on himself, was in possession of two shells and was loading it, all of this relevant information was broadcast to D24 by A/Sergeant Sekoa. These threats of self-harm with a firearm escalated the Victoria Police response with CIRT tactical units, CIRT negotiators, Canine units and further Uniform units responding and commencing to travel to the location.

58. A/Sergeant Sekoa then made arrangements for a cordon to be established to prevent any vehicle or pedestrian traffic from passing their location. First Constable Szabo and Constable Knight (Caroline Springs 311) attended and were tasked with attending the rear of Mr Kudrin’s property to establish a perimeter there and prevent him from leaving that location via that route. A Command Post location was nominated and A/Sergeant Sekoa conducted a safety briefing over the D24 channel. Ambulance Victoria and the Metropolitan Fire Brigade were also requested to attend and hold at the Command Post pending further developments in this incident. Approximately 10.56pm Senior Sergeant Dolman (Melton 265) attended the location, was briefed and assumed responsibility as the Police Forward Commander. Minutes later the Inspector Regional Response Officer (NORTH150) was subsequently briefed as to the unfolding situation.

59. At 11.05pm Melton 251 broadcast that they were still engaging with and conversing with Mr Kudrin from a distance. At that time on-air enquiries were made in respect of the estimated time of arrival for CIRT and the CIRT 251 Supervisor advised that they were 20-25 minutes away from the location.

60. At 11.20pm Canine 237 arrived on scene followed two minutes later by Canine 238 to support the ongoing operation. Critical Incident Response Team Leader, Negotiators and members were still enroute as was the CIRT armoured vehicle.

61. Unexpectedly and without warning, at 11.25pm whilst conversing with First Constable Gillen Mr Kudrin shouted words to the effect of ‘that’s it I’m done talking to you, you are just wasting my time’. First Constable Gillen then heard what he thought sounded like a glass sliding door close and lost sight of Mr Kudrin. He immediately turned to A/Sergeant Sekoa saying ‘I’ve lost comms with him, he went back inside’.

62. Seconds later all of the Officers standing outside heard a single loud noise that they believed to be a gunshot come from the last known direction of Mr Kudrin. A/Sergeant Sekoa directed all uniform units to hold their position in the event that it had been an accidental discharge. First Constable Gillen attempted to recommence communications with Mr Kudrin both verbally and by mobile telephone however all attempts were unsuccessful. The decision not to make immediate entry and render medical assistance was made due to the risk to members and paramedics and the unknown status at that time of Mr Kudrin.

63. Approximately 11.26pm A/Sergeant Sommers and Senior Constable Kitching (CIR211) drove over the front of the residential address to ascertain if there were injured persons and/or movement from within however observed nothing. They immediately proceeded to the Command Post and were the first unit from the Critical Incident Response Team to arrive. CIRT Negotiators Leading Senior Constable Ramirez and Senior Constable Mancini (NEG211) arrived on scene at 11.28pm followed by a number of other CIRT units. At 11.35pm Senior Sergeant Morley (CIR260, CIRT Duty Officer (Tactical Advisor)) arrived on scene.

64. The communications that First Constable Gillen had with Mr Kudrin were not recorded on his Body Worn Camera footage as he had commenced his shift at Melton Police Station and the relevant equipment was stored at Caroline Springs Police Station.

65. Approximately 12.11am the CIRT team moved forward in their armoured vehicle and recommenced attempting to raise Mr Kudrin however without response. Approximately 12.37am CIRT were authorised to breach the address and conduct a clearance whereupon Mr Kudrin was located lying on the bed in the main upstairs bedroom and he was subsequently confirmed as deceased. A homemade firearm was observed at the foot of the bed on the floor.

66. Carriage of the investigation was assigned to the Victoria Police Homicide Squad overseen by the Victoria Police Professional Standards Command. A Critical Incident was declared, and First Constable Gillen, A/Sergeant Sekoa and Senior Sergeant Dolman all underwent mandatory drug and alcohol testing with all results returned negative. A crime scene was established at the residence and examined by the Major Crime Scene Unit and Ballistics Unit, Forensic Services Department.

67. Leading Senior Constable Bamford, Ballistics Unit made the following observations throughout the forensic crime scene examination conducted: a) The residence within which Mr Kudrin was located was a two-storey townhouse in a residential location with a west facing frontage. The front yard was enclosed by a white picket type fence and an upstairs balcony which faced onto St Georges Way. The balcony could only be accessed via the upstairs master bedroom. The ground level of the residence had two living areas, a study, bathroom, and kitchen. The upstairs area contained three bedrooms and a bathroom, the master bedroom also had a walk-in robe which led to another small bathroom.

b) The front door frame was damaged on the inside, there being evidence of the door having been forced open.

c) Within the study all computer screens had been smashed, a computer keyboard wrecked, and a picture frame broken on the ground. There was other evidence throughout the home of malicious damage, with all TV screens smashed and a deep gouge in the door of the fridge.

d) Mr Kudrin was lying on the bed in the master bedroom with a gunshot wound to the head. The point of entry of the shot column was under the chin. The deceased had a cut to the second finger on his left hand, and the knuckes also appeared swollen. Blood spatter was also observed on the back of his left hand.

e) The backyard was accessed via a sliding door in the dining area. The backyard was neat and tidy and led to the door of the garage. Inside the garage was a vehicle that had malicious damage to the windscreen, windows and panels.

68. At a later date Leading Senior Constable Bamford examined the homemade firearm and observed ‘it was a disassembled, 12-gauge home-made, single shot shotgun. The shotgun was constructed of galvanised pipe and other metal components. Located inside the barrel section of the shotgun was a 12-gauge fired cartridge case of Winchester brand, marked ‘Supreme 9’. The parts of the shotgun consisted of:

1. A barrel section threaded at the chamber end

2. A connector pipe threated at both ends

3. A hollow receiver tube threaded at both ends

4. A striker assembly, containing a fixed firing pin, action spring and end cap

5. Leading Senior Constable Bamford noted that ‘the shotgun is fired by the action of pulling a screw attached to the striker assembly rearward, then releasing it. The forward motion of the compressed action spring forces the firing pin into contact with the head of the shotgun cartridge, resulting in discharge’. Leading Senior Constable Bamford test-fired the shotgun using primed cases only and found it to be capable of discharge.

6. Leading Senior Constable Watson, Ballistics Unit subsequently conducted a comparison between these test-fired cartridge cases and the fired 12-gauge shotgun cartridge case located within the homemade firearm and subsequently opined ‘that the fired shotgun cartridge case had been discharged in the exhibit ‘homemade’ shotgun’.

COMMENTS

71. I make the following comments connected with the death of Mr Kudrin pursuant to section 67(3) Coroners Act 2008.

CPU Referral | Service of FVIO

72. For the purposes of the Family Violence Protection Act 2008 (Vic) (FVPA), the available evidence suggests that Valentina experienced family violence in the lead up to the fatal incident. In light of this death occurring in circumstances of family violence, I requested that the Coroner’s Prevention Unit (CPU)12 examine the circumstances of Mr Kudrin’s death as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD).13

73. The main issue identified in this case was the service of the interim FVIO. Victoria Police explained that COVID-19 related resourcing issues impacted their ability to allocate resources to locate Mr Kudrin. Nevertheless, they advised that they made numerous attempts to locate him by calling and sending text messages, placing a ‘whereabouts’ on LEAP, tracing his phone location twice, attending his neighbour’s address, and requesting his address from Centrelink. Unfortunately, despite their efforts, Victoria 12 The CPU was established in 2008 to strengthen the prevention role of the coroner. The CPU assists the coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations. CPU staff include health professionals with training in a range of areas including medicine, nursing, and mental health; as well as staff who support coroners through research, data and policy analysis.

13 The VSRFVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition the VSRFVD collects and analyses information on family violence-related deaths. Together this information assists with the identification of systemic prevention-focused recommendations aimed at reducing the incidence of family violence in the Victorian Community.

Police were unsuccessful in locating Mr Kudrin and serving the FVIO. I make no criticism of Victoria Police’s efforts to serve the FVIO and note that the COVID-19 pandemic had significant impacts on Victoria Police’s resources. It is not uncommon for perpetrators to attempt to evade police, particularly if they know that police are seeking to serve a warrant, criminal charges and/or an FVIO on them.

74. When Victoria Police returned the unserved FVIO to the Sunshine Magistrates’ Court on 21 January 2021, the Sunshine Magistrates’ Court wrote to Valentina to advise her of this outcome. They also asked her to contact the court if she became aware of Mr Kudrin’s residential or work address but did not mention the possibility of serving the FVIO via some other means (e.g., email).

75. Pursuant to section 202A FVPA, the court may order alternative service of an FVIO if it is satisfied that: a) service other than personal servicei. is likely to bring the document to the attention of the person to be served; and ii. will not pose an unacceptable risk to the safety of the affected family member, protected person or any other person; and b) it is appropriate in all the circumstances to make the order.

76. The court may also make an order for alternative service on its own initiative.14

77. As the FVIO application was made by Valentina personally, as opposed to being made by Victoria Police or with the assistance of a solicitor, it is unlikely that Valentina would have been aware of the section 202A provisions for alternative service. If Victoria Police were involved in the application and/or Valentina was legally represented, it is highly likely that an application for alternative service via email would have been made, given that Mr Kudrin continued to send abusive emails and therefore his email account was known to be correct and active.

14 Section 202A(2) FVPA.

78. It is not uncommon for victim-survivors to have to navigate the court system without assistance. I cannot determine that timely service of the interim FVIO would have prevented the fatal incident, however, it would have offered an additional opportunity to engage with Mr Kudrin and to bring him before a court, to hold him responsible for his behaviour.

79. At my direction, the Court contacted the MCV to discuss a proposal to modify the FVIO application form to include an option for alternative service. In response, the MCV explained that it was concerned that any modification to the FVIO application form may have the unintended consequences of creating an additional burden for victim-survivors in attempting to navigate the court process.

80. It is clear that this is not a straightforward issue and may require consultation from many stakeholders within the family violence sector. MCV also referenced Premier Jacinta Allen’s announcement of a ‘new package of reforms’ on 30 May 2024, including a new presumptive minimum length for FVIOs, changes to the stalking offence and upgrades to the Central Information Point, amongst other initiatives. In correspondence between the Court and the Department of Justice and Community Safety (DJCS), Deputy Secretary Marian Chapman confirmed that as of October 2024, work was ‘currently in its early stages’ and that DJCS was unable to confirm specific details. Deputy Secretary Chapman explained that legislative amendments were expected to be introduced to Parliament in 2025.

81. I accept that the issue of FVIO service is complex, and various stakeholders will have differing views about what changes, if any, should be made to the service of FVIOs. It is important that any changes to assist victim-survivors do not have any unintentional consequences for other parties or stakeholders. In circumstances where the Victorian Government is already considering legislative change, I do not propose to make any specific recommendations, however it would be prudent for the Government to consider the circumstances of Mr Kudrin’s death, when considering any legislative change. I therefore intend to provide a copy of this finding to DJCS, for their consideration as part of their legislative review.

Examination of Victoria Police’s response on 7 July 2021 and whether it was appropriate and in accordance with policy

82. The circumstances described in paragraphs [43]-[65] above establish a definitive timeline in respect of Victoria Police’s response following the triple zero call made by Valentina Kudrin’s neighbour at 10.19pm.

83. As assessment of this timeline confirms that Victoria Police initiated a timely response in respect of the initial complaint made in respect of Mr Kudrin’s alleged FV offending that evening. From the time of the first D24 broadcast, Melton 310 (first responding Uniform divisional van) was on-scene and taking a statement from Valentina Kudrin within eight minutes.

84. Further Victoria Police initiated an appropriate response in respect of the intelligence that Mr Kudrin may be armed with a firearm, with all responding Police members prioritising Officer safety and maintaining a safe distance from the premises and balcony upon which Mr Kudrin was located. Upon further confirmation that Mr Kudrin was armed with a firearm (notably First Constable Gillen’s observations and interactions with Mr Kudrin), specialist units including both the Canine Unit and the Critical Incident Response Team (CIRT) were notified, briefed and immediately mobilised in respect of the developing incident.

85. Command and control was clearly implemented with the 251 Patrol Supervisor A/Sergeant Sekoa the initial Police Forward Commander, handing over to the 265 Divisional Patrol Supervisor Senior Sergeant Dolman upon his arrival on-scene. At all times there was clear evidence that both the Divisional Patrol Supervisor and the Inspector, Regional Response Officer were briefed as to the ongoing negotiations and continually kept appraised of ongoing developments.

86. Regrettably Mr Kudrin took the decision to end his life prior to the arrival of the CIRT Negotiators who were approximately one minute away from the location prior to Mr Kudrin self-discharging the homemade firearm. It is purely speculative whether the CIRT Negotiators would have successfully dissuaded Mr Kudrin from taking the course that he did. Regardless I make no criticism whatsoever of the efforts made by First Constable Gillen who negotiated with and spoke with Mr Kudrin from approximately 10.53pm to 11.25pm. First Constable Gillen attempted to engage with Mr Kudrin across a range of topics, avoid or steer the conversation away from those that were highly emotive or triggering, whilst awaiting the attendance of specialist CIRT negotiators. It is clear from all available evidence that Mr Kudrin’s decision at 11.25pm to abruptly cease interactions with First Constable Gillen was unexpected and without warning, and could not have been foreseen, nor prevented.

87. Noting the relevant excerpts from the Victoria Police Manual – Specialist Support, I find that it was appropriate and in accordance with policy to activate both the Canine Unit and the Critical Incident Response Team, with both specialist units responding in a timely manner (noting the distance and corresponding travel time from the Melbourne CBD to Caroline Springs). I find that both specialist units responded in a timely manner despite Mr Kudrin’s unforeseen decision to self-harm immediately after or prior to their respective arrivals.

88. As part of the coronial investigation enquiries were made in respect of the availability of a PACER (Police and Clinical Emergency Response) unit on the 7 July 2021. Those enquiries indicated that the available PACER unit operated out of the Keilor Downs Police Station with the catchment area for the Sunshine Hospital covering the Police response zones of Melton, Sunbury and Brimbank. That evening the PACER unit was staffed by Senior Constable Gatt and a mental health clinician. Senior Constable Gatt commenced duty at 2pm and concluded duty at 10pm and was therefore off-shift at the time this incident occurred.

89. I also note that apart from Mr Kudrin’s s.351 mental health transfer in October 2019, he had no formal diagnoses in respect of his mental health. Mr Kudrin’s regular GP was Dr Saeed, Community Hub Medical Centre, Sydenham who stated ‘Mr Kudrin suffers chronic back pain, hypertension, hypothyroidism, hyperlipidaemia but he stop taken most of his medications since separated from his wife … … he denied depression and suicidal idea’. Mr Kudrin’s Medicare/PBS records substantiate that he did not consult with any medical practitioner in the two years prior to his passing.

90. The conduct of all Victoria Police members that evening were consistent with a cordon and contain strategy that was consistent with Victoria Police policy and demonstrated due regard to the safety of the public, Police members and Mr Kudrin himself. On all the available evidence I find that the response of Victoria Police that evening was in accordance with their policies and procedures, and they provided a timely and appropriate response to the incident as it presented itself, not withstanding Mr Kudrin’s decision to self-harm just prior to the arrival of the CIRT negotiators and tactical units.

STATUTORY FINDINGS AND CONCLUSION

91. Pursuant to section 67(1) of the Coroners Act I make the following findings: a. the identity of the deceased was Nicky Kudrin, born 1 July 1961; b. the death occurred on 7 July 2021 at Caroline Springs, Victoria from I(a) GUNSHOT

WOUND TO THE HEAD; c. in the circumstances described above at paragraphs [35] to [70].

92. I accept and adopt the cause of death as ascribed by Forensic Pathologist, Dr Melanie Archer, and I find that Nicky Kudrin died from a self-inflicted gunshot in circumstances where I find that he intended to take his own life. In having made such finding, I note the absence of identified suspicious circumstances, the lethality of the means chosen, and the evidence pointing to Mr Kudrin’s stressors from his marital breakdown.

93. I find that the response of Victoria Police that evening was in accordance with their policies and procedures, and they provided a timely and appropriate response to the incident as it presented itself, notwithstanding Mr Kudrin’s decision to self-harm just prior to the arrival of the CIRT negotiators and tactical units.

I convey my sincerest sympathy to the family of Nicky Kudrin. I note that the coronial investigation into his death has been a lengthy one, and I am grateful for his family’s patience in this regard.

DIRECTIONS

94. I order that this finding be published on the internet in accordance with section 73(1B) Coroners Act and the Rules.

95. I direct that a copy of this finding be provided to the following: a. The Family of Nicky Kudrin; b. Shane Patton APM, Chief Commissioner of Police; c. Secretary, Department of Justice and Community Safety; d. Professional Standards Command, Victoria Police; e. Detective Senior Sergeant Simon Florence, Coroner’s Investigator.

Signature:

CORONER JOHN OLLE Date: January 31, 2025 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an inquest. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.