Behind locked doors

It is 10 a.m. on a Monday morning as I drive towards Broadmoor Hospital. Suddenly, the air is pierced by a loud siren. The rest of Crowthorne village continues to go about its business, ignoring the noise. At 10.05 a.m. the siren sounds again. I am now at the entrance of the high-security hospital which houses some of Britain's most notorious killers. My natural anxiety as a first-time visitor to this world-famous institution is heightened by the noise of the siren. Has someone escaped?

The lack of activity accompanying the alarm is the giveaway. I learn later that this is a weekly test for the real thing. Hearing the alarm at any other time is a signal to the community that an escape has taken place and that schools and other institutions should be locked up.

The distinctive siren was introduced in 1952 following the escape of J.T. Straffen, who murdered a young girl during his time at large. An inquiry into the escape later recommended: "a distinctive siren or other audible warning, which should be operated by the responsible officer on duty at Broadmoor, should be sounded as soon an escape has been detected". The BBC was also asked to give priority to the announcement of an escape.

The most recent escape attempt was over 10 years ago, when a patient fell attempting to get over the perimeter wall. He broke his leg, defeated by the high walls, now electronically monitored. Broadmoor is home to Peter Sutcliffe, the Yorkshire Ripper, infamous for a series of murders and attacks on women in the late 1970s. One of the Kray brothers also spent time at the hospital.

Both these individuals represent a typical patient profile. Sutcliffe is someone who is clearly a danger to others. Kray arrived at the hospital through the prison service to receive treatment for a psychiatric condition which developed while he was in custody.

The majority of Broadmoor patients have a well-defined psychiatric illness. Many suffer from psychoses, a group of disorders in which the individual's grip on reality is tenuous. Unlike neurotic disorders, a psychotic patient may genuinely believe that he is another person living in another dimension. Psychosis can be a feature of schizophrenia, severe depression or mania. In many cases it can be successfully treated using drugs called major tranquillisers.

Personality disorder remains a clinical challenge, however. There is no tablet or injection for this condition. Psychopathic disorders would be a common category amongst patients of a special hospital such as Broadmoor. These personality disorders are associated with impulsivity, emotional coldness, anti-social behaviour and an absence of guilt.

The modern Broadmoor Hospital has come a long way from the original Criminal Lunatic Asylum, built in 1857. Seen as ground-breaking in its day, Broadmoor can trace its genesis to the 1854 Commission of Lunacy report, which drew the British government's attention to the unsatisfactory conditions in the criminal wards of Bethlehem Hospital.

A site of 290 acres was chosen in the Berkshire moors, then in the countryside, 32 miles from central London. Reflecting the stigmatisation of mental illness prevalent at the time, the location was perfectly suited to the concept of isolating the mentally ill from the rest of the community. Major General Joshua Jebb KCB, a brilliant military engineer, designed the new establishment, reputedly copying the better parts of two hospitals - Wakefield and Scutari Hospital in Turkey, where Florence Nightingale worked. Construction workers were transported from Parkhurst Prison on the Isle of Wight, camping out on the moors until the first buildings were ready for occupation. The original design had six blocks of 400 beds for men and one block of 100 beds for women. A chapel, workshop, kitchen garden and a cemetery were included. One hundred and sixty seven acres of cultivated land along with farm buildings lay within the estate. Four and a half miles of road were laid and three detached houses built for the use of the most senior officers. Fifty seven cottages housed other staff. Sir Joshua also included a school, with a residence for two school mistresses.

The marvellous setting of Broadmoor, set 450 feet above sea level and with commanding views of counties Surrey, Hampshire and Berkshire, can still be appreciated today. The views to the south and southwest were felt to have therapeutic benefits at the time of construction; a present-day visitor comes away from the hospital with a feeling of peace.

The concept of Criminal Lunacy can be traced back to January 20th, 1843, when a Daniel McNaughton shot Edward Drummond, private secretary to Sir Robert Peel. He pleaded insanity with the support of five doctors and was acquitted. The British public, and Queen Victoria, was outraged, despite the fact that McNaughton would be incarcerated for the rest of his life. He died of heart failure at Broadmoor in 1865, aged 52.

Following the public outcry, the entire English judiciary clarified the verdict on June 19th, 1843, by answering five hypothetical questions put to them. These questions and answers became known as the "McNaughton Rules," which still determine how "mad" a person must be in order to be found not guilty of a criminal offence.

The crucial question, as defined in 1843 was: "Is the prisoner, at the time of the offence, suffering from such a defect of reason of the mind as not to know the nature and quality of the act which he was doing as not to know that it was wrong". The "Mc Naughton Rules" thus defined criminal responsibility, rather than insanity itself.

The Criminal Lunatics Act of 1860 was passed "to make better provision for the custody and care of criminal lunatics and for regulation of criminal lunatic asylums". Known as the Broadmoor Act, the legislation gave the British Home Secretary control over all criminal lunatics, a responsibility which remained with the Home Office until 1948. Crucially, Broadmoor asylum was "to be intended for the reception, safe custody and treatment of persons who had committed crimes whilst actually insane or who became insane whilst undergoing sentence of punishment".

The opening of Broadmoor was therefore a significant step forward in separating "criminal lunatics" from other patients. It also set down a marker that their liberation, as a matter of course, could not be sanctioned due to the danger to society.

Dr John Meyer was the first Physician Superintendent at Broadmoor, taking up his post in 1863. The following year he was attacked by a patient while attending Holy Communion in the hospital chapel with his family. Although he recovered, he was reported to "have lost his nerve" and retired four years later. Security was generally poor during the early years, with staff drunk on duty and a highly variable application of rules and procedures.

A Dr Orange succeeded Dr Meyer and he set about eradicating the epidemic of mild fever which had persisted since the hospital's opening. Dr Orange was an excellent organiser and it was during his tenure that Broadmoor changed from an experimental concentration camp for homicidal lunatics to a well-run, permanent medical establishment.

March 2nd, 1882, was another milestone in the definition of criminal insanity. Roderick McClean shot at, but missed, Queen Victoria on the platform of Windsor station. He was found "not guilty by reason of insanity" Queen Victoria was outraged, and famously remarked: "insane he may be, but guilty he certainly was". A Criminal Act of 1883 hastily changed the phraseology to "guilty but insane".

In 1914, a more generous policy of patient release from Broadmoor was instituted. Also during the first World War, German prisoners deemed mentally ill and dangerous were housed there. Broadmoor was bombed by the Germans on November 2nd, 1940. One bomb blew a crater 15 feet by five feet close to a block called Somerset House, but no one was injured.

The Criminal Justice Act of 1948 saw a formal recognition of the curative role of Broadmoor. Its title changed from "Institution" to "Hospital" and ownership transferred to the Department of Health and Social Security.

Greater integration with the rest of the NHS came about in 1989 with the creation of a Special Hospitals Services Authority. The new authority was charged with ensuring the continuing safety of the public, providing appropriate treatment for patients, and ensuring a good quality of life for both patients and staff.

Today Broadmoor has 400 patients, 80 of whom are women. The average length of stay is eight years, with almost 50 admissions per year. Twenty per cent of patients have a personality disorder, with the majority of the remainder suffering from psychosis. To be admitted, you must be considered a danger to yourself or others, and you must be assessed as having a treatable mental disorder.

There are 13 consultant forensic psychiatrists working at Broadmoor, one of whom is a TCD graduate, Dr Damien Mohan. All patients have to be approved by a multidisciplinary admissions panel, after which they spend between three and nine months on an assessment ward.

Approximately 90 staff members are involved in patient rehabilitation. This number includes 11 social workers, four occupational therapists, and three creative therapists specialising in drama, art and music.

A patient education centre offers further education opportunities. Some teaching takes place on the wards. There are four fulltime staff, complemented by part-time tutors.

The patients' football team is part of a local league; matches are played in the hospital grounds. There is a similar arrangement for cricket and bowls.

The atmosphere in the hospital is less tense than you might imagine. There is an artificial stillness on the roads and paths between the units. All staff carry a leather pouch containing numerous keys to allow them to navigate the grounds.

Broadmoor's Irish equivalent is the Central Mental Hospital in Dublin. Although commissioned at the same time as the Berkshire hospital, it actually became one of the first asylums in Europe because it was built more quickly. As for the future, there are proposals to integrate Broadmoor even more into the mainstream NHS. Plans were announced in 1999 to merge with a London Mental Health Trust.

In July this year, the House of Commons health select committee called for the regionalisation of high-security units such as Broadmoor. MPs believe that smaller, purpose-built units offer better security for the public, patients, and staff.

As a visitor to Broadmoor, I would rate its security as high level. I was x-rayed before being allowed in. As part of the body search, a packet of mints was politely but carefully examined in case it represented an attempt to smuggle drugs into the unit. Notepaper was supplied from within; cameras and tape recorders were not allowed.

The people of Crowthorne accept Broadmoor's presence in their community with equanimity. Now part of the Thames "Silicon" Valley, the housing in the vicinity is that of an upmarket stockbroker belt. The world has moved on since the pioneering days of the 1860s when "out of sight, out of mind" was a key concept in achieving public approval for an asylum. Now, with integration a byword, Broadmoor's lack of isolation is an appropriate pointer to the future development of forensic psychiatry.