The incidence of hard-to-heal wounds is rising globally with adverse effects on quality of life. Yet, there is no reliable data available on hard-to-heal wound prevalence, aetiology, and outcomes in a low-to-middle income country without improper care being a confounding factor. In this retrospective study of 460 individuals (876 wounds) that received appropriate standard of care at a specialised wound care clinic in the Kwazulu-Natal province of South Africa, acute/traumatic wounds were most prevalent (230/460, 50%) followed by ulcers (173/460, 38%) (DFUs 13%, VLUs 12%, PIs 11%, MLUs < 1%, ALUs < 1%) and atypical wounds (55/460, 12%) (atypical wounds 8%, vectors 4%). Definitions for wound aetiologies are provided. Delayed referral for specialised wound care was evident for individuals with ulcers. 103/460 (22%) individuals did not respond to the standard of care and were classified as hard-to-heal (< 40% wound closure after 4 weeks and/or > 12 weeks of the standard of care). Diabetes mellitus (45/103, 44%) and wound infection (44/103, 43%) accounted for poor healing trajectories in the hard-to-heal cohort, whereas 14/103 (13%) individuals had other comorbidities. High prevalence rates of hard-to-heal wounds in the heterogenous South African population necessitate recognition of wound management as a specialty in South Africa.